OBJECTIVE:To perform a meta-analysis addressing whether enteral nutrition with immune-enhancing feeds benefits critically ill patients after trauma, sepsis, or major surgery.
DATA SOURCES:Studies ...were identified by MEDLINE search (1967 to January 1998) for original articles in English using the search terms "human," "enteral nutrition," "arginine," "nucleotides," "omega-3 fatty acids," "immunonutrition," "IMPACT," and "Immun-Aid." Additionally, the authors of the studies and the manufacturers of the feeds were contacted for additional information. Access to original databases was obtained for the three largest studies.
STUDY SELECTION:Fifteen randomized controlled trials comparing patients receiving standard enteral nutrition with patients receiving a commercially available immune-enhancing feed with arginine with or without glutamine, nucleotides, and omega-3 fatty acids were identified by two independent reviewers (Dr. Beale and Dr. Bryg).
DATA EXTRACTION:Descriptive and outcome data were extracted independently from the papers by the same two reviewers, one of whom (Dr. Bryg) analyzed the original databases. Three studies were excluded from analysis, leaving 12 studies containing 1,557 subjects, 1,482 of whom were analyzed. Main outcome measures were mortality, infection, ventilator days, intensive care unit stay, hospital stay, diarrhea days, calorie intake, and nitrogen intake. The meta-analysis was performed on an intent-to-treat basis.
DATA SYNTHESIS:There was no effect of immunonutrition on mortality (relative risk = 1.05, confidence interval CI = 0.78, 1.41; p = .76). There were significant reductions in infection rate (relative risk = 0.67, CI = 0.50, 0.89; p = .006), ventilator days (2.6 days, CI = 0.1, 5.1; p = .04), and hospital length of stay (2.9 days, CI = 1.4, 4.4; p = .0002) in the immunonutrition group.
CONCLUSIONS:The benefits of enteral immunonutrition were most pronounced in surgical patients, although they were present in all groups. The reduction in hospital length of stay and infections has resource implications.
OBJECTIVE:Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in ...the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP).
DATA SOURCES AND METHODS:An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis.
DATA SYNTHESIS:There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2–3 wk to allow for demarcation of the necrotic pancreas.
CONCLUSIONS:This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
To compare the safety and efficacy of high frequency oscillatory ventilation (HFOV) with conventional mechanical ventilation (CV) for early intervention in adult respiratory distress syndrome (ARDS), ...a multi-centre randomized trial in four intensive care units was conducted.
Patients with ARDS were randomized to receive either HFOV or CV. In both treatment arms a priority was given to maintain lung volume while minimizing peak pressures. CV ventilation strategy was aimed at reducing tidal volumes. In the HFOV group, an open lung strategy was used. Respiratory and circulatory parameters were recorded and clinical outcome was determined at 30 days of follow up.
The study was prematurely stopped. Thirty-seven patients received HFOV and 24 patients CV (average APACHE II score 21 and 20, oxygenation index 25 and 18 and duration of mechanical ventilation prior to randomization 2.1 and 1.5 days, respectively). There were no statistically significant differences in survival without supplemental oxygen or on ventilator, mortality, therapy failure, or crossover. Adjustment by a priori defined baseline characteristics showed an odds ratio of 0.80 (95% CI 0.22-2.97) for survival without oxygen or on ventilator, and an odds ratio for mortality of 1.15 (95% CI 0.43-3.10) for HFOV compared with CV. The response of the oxygenation index (OI) to treatment did not differentiate between survival and death. In the HFOV group the OI response was significantly higher than in the CV group between the first and the second day. A post hoc analysis suggested that there was a relatively better treatment effect of HFOV compared with CV in patients with a higher baseline OI.
No significant differences were observed, but this trial only had power to detect major differences in survival without oxygen or on ventilator. In patients with ARDS and higher baseline OI, however, there might be a treatment benefit of HFOV over CV. More research is needed to establish the efficacy of HFOV in the treatment of ARDS. We suggest that future studies are designed to allow for informative analysis in patients with higher OI.
OBJECTIVE:To evaluate an intravenous meropenem dosage regimen in adult intensive care patients with acute renal failure treated by continuous renal replacement therapy.
DESIGN:A prospective, clinical ...study.
SETTING:General intensive care unit of a university hospital.
PATIENTS:Ten critically ill adult patients being treated with meropenem and receiving continuous veno-venous hemofiltration (hemofiltration rates, 1-2 L/hr) (n = 5) or continuous veno-venous hemodiafiltration (hemofiltration rates, 1-1.5 L/hr; dialysis rates, 1-1.5 L/hr) (n = 5) via a polyacrylonitrile hollow fiber 0.9-m filter.
INTERVENTIONS:Patients received a meropenem dose of 1 g iv every 12 hrs as a 5-min bolus.
MEASUREMENTS AND MAIN RESULTS:Meropenem concentrations were measured by high-performance liquid chromatography in serum taken at timed intervals and in ultrafiltrate/dialysate to determine serum concentration-time profiles, derive pharmacokinetic variable estimates, and determine sieving coefficients and filter clearances. The serum concentrations were examined to see whether they were above the minimum inhibitory concentrations (MICs) for pathogens that may be encountered in intensive care patients. Serum concentrations exceeded 4 mg/L (MIC90 for Pseudomonas aeruginosa) during 67% of the dosage period in all patients. Sub-MIC90 concentrations were obtained in three patients immediately before treatment and in one patient 12 hrs after treatment. Mean (SD) (n = 10) pharmacokinetic variable estimates were as followselimination half-life, 5.16 hrs (1.83 hrs); volume of distribution, 0.35 L/kg (0.10 L/kg); and total clearance, 4.30 L/hr (1.38 L/hr). A sieving coefficient of 0.93 (0.06) (n = 9) indicated free flow across the filter. The fraction cleared by the extracorporeal route was 48% (13%) (n = 9), which is clinically important.
CONCLUSIONS:A meropenem dose of 1 g iv every 12 hrs provides adequate serum concentrations in the majority of patients receiving continuous veno-venous hemofiltration or continuous veno-venous hemofiltration with a 0.9-m polyacrylonitrile filter at combined ultrafiltrate/dialysate flow rates of up to 3 L/hr. A lower dose would not be sufficient for the empirical treatment of potentially life-threatening infections in all patients.
To evaluate the influence of perfusion temperature on the systemic effects of cardiopulmonary bypass (CPB), including extravascular lung water index (EVLWI), and serum cytokines.
Prospective, ...randomized, controlled study.
Cardiothoracic intensive care unit of a university hospital.
Patients undergoing elective coronary artery bypass grafting.
Twenty-one patients undergoing elective coronary artery bypass grafting were randomly assigned to receive either normothermic bypass (36 degrees C, n = 8) with intermittent antegrade warm blood cardioplegia (IAWBC), or hypothermic (32 degrees C, n = 13) CPB with cold crystalloid cardioplegia.
Mean arterial pressure, heart rate, cardiac output, systemic vascular resistance, mean pulmonary arterial pressure, and pulmonary vascular resistance were determined at baseline, i.e., after induction of anesthesia but before sternal opening (T-1), at arrival in the intensive care unit (T0), and 4 hrs (T4), 8 hrs (T8), and 24 hrs (T24) after surgery. EVLWI, intrathoracic blood volume index (ITBVI), and EVLW/ITBV ratio were obtained by using thermal dye dilution utilizing an arterial thermistor-tipped fiberoptic catheter and were recorded at T-1, T0, T4, T8, and T24. Serial blood samples for cytokine measurements were obtained at each hemodynamic measurement time point. Before, during, and after CPB, there were no differences in the conventional hemodynamic measurements between the groups. There were no changes in EVLWI up to T8 in either group. Furthermore, no change in the ratio EVLW/ITBW was observed between the groups at any time, further indicating the absence of a change in pulmonary permeability. Plasma levels of interleukin-6, tumor necrosis factor-alpha, and interleukin-10 increased during and after CPB, independently of the perfusion temperature.
Normothermic CPB is not associated with additional inflammatory and related systemic adverse effects regarding cytokine production and EVLWI as compared with mild hypothermia. The potential temperature-dependent release of cytokines and subsequent inflammation has not been observed and normothermic CPB may be seen as a safe technique regarding this issue.
to compare the outcome of patients undergoing non-elective abdominal aortic aneurysm repair at two hospitals under the care of a single vascular surgeon.
prospective and retrospective audit of 6 ...years of emergency and urgent infrarenal abdominal aortic aneurysm surgery.
Lewisham and North Southwark Health Authority.
one hundred and forty-five patients who underwent emergency (46) or urgent (99) repair of an abdominal aortic aneurysm.
hospital mortality.
acute renal failure, intensive care and hospital length of stay distal ischaemia and return to theatre.
mortality was higher at hospital 2 than hospital 1 (28% vs. 9%,
p=0.0068). There was no significant difference in age, sex, cardiac history, hypertension, diabetes, smoking, renal impairment (all
p>0.05). There was no difference in operation time, blood loss and base excess at the end of surgery between the two groups (all
p>0.05). APACHE II scores on admission to ICU were similar in hospital 1 and hospital 2 (median 16 vs. 14,
p>0.03). Pulmonary artery catheters were placed in 18% of patients at hospital 1 compared with 96% at hospital 2. Patients at hospital 2 received more crystalloid (median 2990 vs. 2300 ml ÷, more colloid (median 4775 vs. 1500 ml), and more inotropes (median 1 vs. 0) than those at hospital 1 in their first 24 h on ICU (all
p<0.001). The volume of urine passed in the first 24 h was similar (median 2410 vs. 2000 ml,
p=0.12) yet the incidence of acute renal failure was higher at hospital 2 compared with hospital 1 (30% vs. 6%, p=0.001). ICU length of stay of survivors was longer at hospital 2 (median 3 vs. 2 days,
p=0.0018) as was hospital length of stay (median 17.5 vs. 12 days,
p=0.0002).
the outcome at both hospitals is at least as good as other reported series, but it is interesting to note that the hospital which used less pulmonary artery catheters and less intervention (in the form of colloid and inotropes) showed a reduced mortality. These data may be important in assessing the different therapeutic strategies employed postoperatively in the ICU.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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