Limited data are available assessing vancomycin concentrations in obese critically ill patients. Currently, there are no studies evaluating dosing requirements in this population who receive ...vancomycin administered as a continuous infusion (CI). The aim of this study was to assess whether there was a difference in the weight-based maintenance dose required to reach a therapeutic vancomycin concentration at 24 hours when given as a CI in obese versus non-obese critically ill patients.
A retrospective cohort study of adult obese patients admitted to the SICU between 2013 and 2015 receiving a vancomycin CI (CIV), and with 24-hour serum measurements were included. Obese patients (body mass index (BMI) ≥35 kg/m(2)) were matched with non-obese patients (BMI <30 kg/m(2)) based on renal function, age and acute physiology and chronic health evaluation (APACHE)-II score at admission. All patients in this study received a loading dose of 25 mg/kg then a maintenance dose based on renal function according to the protocol. The study was approved by the Institutional Review Board. The primary outcome was the weight-based total daily maintenance dose required to achieve a vancomycin level of 20 mg/L. The secondary endpoints included the achievement of a therapeutic level at 24 hours.
Twenty-six matched pairs of patients met the inclusion criteria. Of these, 17 pairs had preserved renal function and 9 pairs required continuous venovenous hemofiltration. Mean BMI was 40.9 kg/m(2) in obese and 24.8 kg/m(2) in non-obese patients. To achieve a vancomycin concentration of 20 mg/L, the weight-based daily maintenance dose in obese patients was 25.6 mg/kg versus 43.8 mg/kg in non-obese patients (p <0.01). Therapeutic 24-hour levels were achieved in 24/26 obese versus 23/26 no-obese patients (p = 0.63). Mean 24-hour vancomycin level was 20.3 ± 3.81 mcg/ml in obese compared to 20.03 ± 3.79 mcg/ml in non-obese patients (p = 0.77). Mean daily maintenance doses required to achieve a level of 20 mcg/ml were 2961 ± 1670 mg in obese compared to 3189 ± 1600.69 mg in non-obese (p = 0.61).
The results of our study suggest that critically ill obese patients treated with CIV required a significantly lower maintenance dose per unit of body weight than non-obese patients to achieve the same target level.
Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in ...the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.
Ionized fraction (iMg) is the physiologically active form of magnesium (Mg); total Mg may not accurately reflect iMg status. Erroneously “low” Mg levels may result in unnecessary repetitive testing.
...From 11/2015 to 01/2016, patients ordered for Mg from a pilot ICU also had iMg tested. Weighted kappa statistic was used to assess agreement between Mg categories (low, normal, high). Predictors of unnecessary repeated Mg testing and repletion using data were explored through logistic regression models using GEE techniques to account for repeated measurements in both bivariate and multivariable analyses.
There were 470Mg/iMg paired measurements from 173 patients. The weighted kappa statistic was 0.35 (95%CI 0.27–0.43) indicating poor agreement in assessment of magnesium status. Of the 34Mg samples reported as “low”, only 6 (18%) were considered “low” using concurrent iMg testing. In the multivariable models, history of atrial fibrillation (aOR=1.61, 95%CI 1.16–2.21, p=0.004) and concomitant metoclopramide (aOR=1.71, 95%CI 1.03–2.81, p=0.036) were significant predictors of unnecessary repeat Mg testing.
In the surgical ICU, categorical agreement (low, normal, high) was poor between Mg and iMg. Over 80% of “low” total Mg values are erroneous and may result in unnecessary additional measurements and repletion.
•Category agreement between total Mg and ionized Mg (iMg) is poor.•Only 18% of “low” total Mg values are actually low on iMg measurement.•Atrial fibrillation and concomitant metoclopramide predict unnecessary Mg testing.
Background
Despite parenteral nutrition (PN) being life sustaining, one of the risk factors associated with its long‐term use is intestinal failure–associated liver disease (IFALD), which increases ...the risk for morbidity and mortality. This review examines some of the risk factors associated with IFALD.
Methods
A literature review using the databases PubMed, EMBASE, and CINAHL between 2010 and 2020 was performed using search terms, including long‐term total PN and liver failure, serum plant sterols and liver failure, and complications and PN. Articles in English using both human and animal participants were included.
Results
The pathophysiology associated with PN and liver disease is multifactorial and influenced by the remaining small‐bowel length, presence of the ileal cecal valve, lack of enteral stimulation, type of lipid injectable emulsion (ILE), plant sterol content, and excessive calories. The type of ILE plays a major role because of the phytosterol (PS) content, affecting the microbiome composition and inhibiting key gut signals. The PS content is highest in soy oil (SO)–based ILE, which increases inflammation and impairs biliary flow.
Conclusion
Serum PS correlates with liver biomarker abnormalities and is highest in SO‐based ILE use compared with mixed‐oil emulsions. Selection of a low‐PS content ILE is recommended to reduce the risk of biliary cholestasis. Stimulation of the gut, if possible, is recommended to maintain gut integrity and reduce bacterial overgrowth. Fish oil (FO) shows promise in IFALD reversal however, large randomized controlled trials are needed to further establish support for the use of FO in adults.
Abstract Introduction Epidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection ...and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48 h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay. Methods This is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24 h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications. Results 187 patients were included in the analysis; early thoracic epidural was utilised in 18% ( n = 34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy ( p = 0.017). Conclusion In our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.
PDF
