Summary Background Patients admitted to intensive-care units are at high risk of health-care-associated infections, and many are caused by antimicrobial-resistant pathogens. We aimed to assess excess ...mortality and length of stay in intensive-care units from bloodstream infections and pneumonia. Methods We analysed data collected prospectively from intensive-care units that reported according to the European standard protocol for surveillance of health-care-associated infections. We focused on the most frequent causative microorganisms. Resistance was defined as resistance to ceftazidime ( Acinetobacter baumannii or Pseudomonas aeruginosa ), third-generation cephalosporins ( Escherichia coli ), and oxacillin ( Staphylococcus aureus ). We defined 20 different exposures according to infection site, microorganism, and resistance status. For every exposure, we compared outcomes between patients exposed and unexposed by use of time-dependent regression modelling. We adjusted results for patients' characteristics and time-dependency of the exposure. Findings We obtained data for 119 699 patients who were admitted for more than 2 days to 537 intensive-care units in ten countries between Jan 1, 2005, and Dec 31, 2008. Excess risk of death (hazard ratio) for pneumonia in the fully adjusted model ranged from 1·7 (95% CI 1·4–1·9) for drug-sensitive S aureus to 3·5 (2·9–4·2) for drug-resistant P aeruginosa . For bloodstream infections, the excess risk ranged from 2·1 (1·6–2·6) for drug-sensitive S aureus to 4·0 (2·7–5·8) for drug-resistant P aeruginosa . Risk of death associated with antimicrobial resistance (ie, additional risk of death to that of the infection) was 1·2 (1·1–1·4) for pneumonia and 1·2 (0·9–1·5) for bloodstream infections for a combination of all four microorganisms, and was highest for S aureus (pneumonia 1·3 1·0–1·6, bloodstream infections 1·6 1·1–2·3). Antimicrobial resistance did not significantly increase length of stay; the hazard ratio for discharge, dead or alive, for sensitive microorganisms compared with resistant microorganisms (all four combined) was 1·05 (0·97–1·13) for pneumonia and 1·02 (0·98–1·17) for bloodstream infections. P aeruginosa had the highest burden of health-care-acquired infections because of its high prevalence and pathogenicity of both its drug-sensitive and drug-resistant strains. Interpretation Health-care-associated bloodstream infections and pneumonia greatly increase mortality and pneumonia increase length of stay in intensive-care units; the additional effect of the most common antimicrobial resistance patterns is comparatively low. Funding European Commission (DG Sanco).
Summary Background & aims This review aims to clarify the use of indirect calorimetry (IC) in nutritional therapy for critically ill and other patient populations. It features a comprehensive ...overview of the technical concepts, the practical application and current developments of IC. Methods Pubmed-referenced publications were analyzed to generate an overview about the basic knowledge of IC, to describe advantages and disadvantages of the current technology, to clarify technical issues and provide pragmatic solutions for clinical practice and metabolic research. The International Multicentric Study Group for Indirect Calorimetry (ICALIC) has generated this position paper. Results IC can be performed in in- and out-patients, including those in the intensive care unit, to measure energy expenditure (EE). Optimal nutritional therapy, defined as energy prescription based on measured EE by IC has been associated with better clinical outcome. Equations based on simple anthropometric measurements to predict EE are inaccurate when applied to individual patients. An ongoing international academic initiative to develop a new indirect calorimeter aims at providing innovative and affordable technical solutions for many of the current limitations of IC. Conclusion Indirect calorimetry is a tool of paramount importance, necessary to optimize the nutrition therapy of patients with various pathologies and conditions. Recent technical developments allow broader use of IC for in- and out-patients.
Monitoring nutrition in the ICU Berger, Mette M.; Reintam-Blaser, Annika; Calder, Philip C. ...
Clinical nutrition (Edinburgh, Scotland),
April 2019, 2019-04-00, 20190401, Letnik:
38, Številka:
2
Journal Article
Recenzirano
Odprti dostop
This position paper summarizes theoretical and practical aspects of the monitoring of artificial nutrition and metabolism in critically ill patients, thereby completing ESPEN guidelines on intensive ...care unit (ICU) nutrition.
Available literature and personal clinical experience on monitoring of nutrition and metabolism was systematically reviewed by the ESPEN group for ICU nutrition guidelines.
We did not identify any studies comparing outcomes with monitoring versus not monitoring nutrition therapy. The potential for abnormal values to be associated with harm was clearly recognized. The necessity to create locally adapted standard operating procedures (SOPs) for follow up of enteral and parenteral nutrition is emphasised. Clinical observations, laboratory parameters (including blood glucose, electrolytes, triglycerides, liver tests), and monitoring of energy expenditure and body composition are addressed, focusing on prevention, and early detection of nutrition-related complications.
Understanding and defining risks and developing local SOPs are critical to reduce specific risks.
Experimental and volunteer studies have reported pulmonary vasoconstriction during transfusion of packed red blood cells (PRBCs) stored for prolonged periods. The primary aim of this study was to ...evaluate whether transfusion of PRBCs stored over 21 days (standard-issue, siPRBCs) increases pulmonary artery pressure (PAP) to a greater extent than transfusion of PRBCs stored for less then 14 days (fresh, fPRBCs) in critically ill patients following cardiac surgery. The key secondary aim was to assess whether the pulmonary vascular resistance index (PVRI) increases after transfusion of siPRBCs to a greater extent than after transfusion of fPRBCs.
The study was performed as a single-center, double-blinded, parallel-group, randomized clinical trial. Leukoreduced PRBCs were transfused while continuously measuring hemodynamic parameters. Systemic concentrations of syndecan-1 were measured to assess glycocalyx injury. After randomizing 19 patients between January 2014 and June 2016, the study was stopped due to protracted patient recruitment.
Of 19 randomized patients, 11 patients were transfused and included in statistical analyses. Eight patients were excluded prior to transfusion, 6 patients received fPRBCs (10±3 storage days), whereas 5 patients received siPRBCs (33±4 storage days). The increase in PAP (7±3 vs. 2±2 mmHg, P = 0.012) was greater during transfusion of siPRBCs than during transfusion of fPRBCs. In addition, the change in PVRI (150±89 vs. -4±37 dyn·s·cm-5·m2, P = 0.018) was greater after transfusion of siPRBCs than after transfusion of fPRBCs. The increase in PAP correlated with the change of systemic syndecan-1 concentrations at the end of transfusion (R = 0.64,P = 0.034).
Although this study is underpowered and results require verification in larger clinical trials, our findings suggest that transfusion of siPRBCs increases PAP and PVRI to a greater extent than transfusion of fPRBCs in critically ill patients following cardiac surgery. Glycocalyx injury might contribute to pulmonary vasoconstriction associated with transfusion of stored blood.
Cardiopulmonary bypass (CPB) surgery initiates a systemic inflammatory response, which is associated with postoperative morbidity and mortality. Hemoadsorption (HA) of cytokines may suppress ...inflammatory responses and improve outcomes. We tested a new sorbent used for HA (CytoSorb™; CytoSorbents Europe GmbH, Berlin, Germany) installed in the CPB circuit on changes of pro- and anti-inflammatory cytokines levels, inflammation markers, and differences in patients' perioperative course.
In this first pilot trial, 37 blinded patients were undergoing elective CPB surgery at the Medical University of Vienna and were randomly assigned to HA (n = 19) or control group (n = 18). The primary outcome was differences of cytokine levels (IL-1β, IL-6, IL-18, TNF-α, and IL-10) within the first five postoperative days. We also analyzed whether we can observe any differences in ex vivo lipopolysaccharide (LPS)-induced TNF-α production, a reduction of high-mobility box group 1 (HMGB1), or other inflammatory markers. Additionally, measurements for fluid components, blood products, catecholamine treatment, bioelectrical impedance analysis (BIA), and 30-day mortality were analyzed.
We did not find differences in our primary outcome immediately following the HA treatment, although we observed differences for IL-10 24 hours after CPB (HA: median 0.3, interquartile range (IQR) 0-4.5; control: not traceable, P = 0.0347) and 48 hours after CPB (median 0, IQR 0-1.2 versus not traceable, P = 0.0185). We did not find any differences for IL-6 between both groups, and other cytokines were rarely expressed. We found differences in pretreatment levels of HMGB1 (HA: median 0, IQR 0-28.1; control: median 48.6, IQR 12.7-597.3, P = 0.02083) but no significant changes to post-treatment levels. No differences in inflammatory markers, fluid administration, blood substitution, catecholamines, BIA, or 30-day mortality were found.
We did not find any reduction of the pro-inflammatory response in our patients and therefore no changes in their perioperative course. However, IL-10 showed a longer-lasting anti-inflammatory effect. The clinical impact of prolonged IL-10 needs further evaluation. We also observed strong inter-individual differences in cytokine levels; therefore, patients with an exaggerated inflammatory response to CPB need to be identified. The implementation of HA during CPB was feasible.
ClinicalTrials.gov: NCT01879176, registration date: June 7, 2013.
The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill ...patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.
Medical nutrition therapy may be associated with clinical outcomes in critically ill patients with prolonged intensive care unit (ICU) stay. We wanted to assess nutrition practices in European ...intensive care units (ICU) and their importance for clinical outcomes.
Prospective multinational cohort study in patients staying in ICU ≥ 5 days with outcome recorded until day 90. Macronutrient intake from enteral and parenteral nutrition and non-nutritional sources during the first 15 days after ICU admission was compared with targets recommended by ESPEN guidelines. We modeled associations between three categories of daily calorie and protein intake (low: < 10 kcal/kg, < 0.8 g/kg; moderate: 10-20 kcal/kg, 0.8-1.2 g/kg, high: > 20 kcal/kg; > 1.2 g/kg) and the time-varying hazard rates of 90-day mortality or successful weaning from invasive mechanical ventilation (IMV).
A total of 1172 patients with median Q1;Q3 APACHE II score of 18.5 13.0;26.0 were included, and 24% died within 90 days. Median length of ICU stay was 10.0 7.0;16.0 days, and 74% of patients could be weaned from invasive mechanical ventilation. Patients reached on average 83% 59;107 and 65% 41;91 of ESPEN calorie and protein recommended targets, respectively. Whereas specific reasons for ICU admission (especially respiratory diseases requiring IMV) were associated with higher intakes (estimate 2.43 95% CI: 1.60;3.25 for calorie intake, 0.14 0.09;0.20 for protein intake), a lack of nutrition on the preceding day was associated with lower calorie and protein intakes (- 2.74 - 3.28; - 2.21 and - 0.12 - 0.15; - 0.09, respectively). Compared to a lower intake, a daily moderate intake was associated with higher probability of successful weaning (for calories: maximum HR 4.59 95% CI: 1.5;14.09 on day 12; for protein: maximum HR 2.60 1.09;6.23 on day 12), and with a lower hazard of death (for calories only: minimum HR 0.15, 0.05;0.39 on day 19). There was no evidence that a high calorie or protein intake was associated with further outcome improvements.
Calorie intake was mainly provided according to the targets recommended by the active ESPEN guideline, but protein intake was lower. In patients staying in ICU ≥ 5 days, early moderate daily calorie and protein intakes were associated with improved clinical outcomes. Trial registration NCT04143503 , registered on October 25, 2019.
The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European ...Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure.
Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription.
In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice.
While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding.
Acute kidney injury predicts adverse outcomes after cardiac surgery.
To determine whether ultra-short-term changes (within 120 min) in serum creatinine (SCrea) levels after cardiac surgery predict ...clinical outcomes (30-day mortality).
Observational cohort study.
Austrian tertiary referral centre.
A total of 7651 patients scheduled to undergo elective cardiac surgery.
We analysed SCrea levels measured pre-operatively (baseline) and within 120 min after surgery. We also adjusted the postoperative SCrea levels for fluid balance. Patients were grouped according to the difference between the pre and postoperative SCrea levels (ΔSCreaAdmICU). We performed univariable and multivariable analyses to determine the association between changes in SCrea levels and 30-day mortality.
After cardiac surgery, the SCrea level decreased in 5923 patients and increased in 1728 patients. Increased SCrea levels were associated with a 21% increase in 30-day mortality. Even minimal increases in SCrea (0 to <26.5 μmol l) were significantly associated with 30-day mortality hazard ratio (HR), 1.98; 95% confidence interval (CI), 1.54 to 2.55; P < 0.001. Adjustments for fluid balance strengthened the above association (increases of 0 to <26.5 μmol l: HR, 1.78; 95% CI, 1.40 to 2.26; P < 0.001; increases of at least 26.5 μmol l: HR, 2.40; 95% CI, 1.68 to 3.42; P < 0.001).
Even minimal, ultra-short-term increases in SCrea levels after cardiac surgery are associated with increased 30-day mortality. Adjustment for fluid balance strengthens this association. The change in SCrea between baseline and after admission to the Intensive Care Unit (ΔSCreaAdmICU) can serve as a simple, cheap and widely available marker for very early risk stratification after cardiac surgery.
Summary Background & aims Several large and long-term prospective studies have assessed the association of body-mass index (BMI) next to age with the risk of death in the general population, but few ...have examined the association with in-hospital mortality. We investigated the association between BMI, age and in-hospital mortality. Methods We used data collected during 9 consecutive one-day/year surveys (NutritionDay in hospital 2006–2014) conducted in non-critically ill adult patients from 2,183 hospitals across 51 nations from 4 continents. We examined the association of BMI and age with the risk of in-hospital (30-day) death using logistic regression analysis adjusted for multiple confounders. Results Crude mortality rates were 3.6% (95%CI, 3.5–3.7) and 2.1% (95%CI, 2.0–2.3) in the overall cohort (N = 97,344) and in those assessed within 72 hours since admission (N = 32,363), respectively. BMI and age were independently associated with the risk of death (no interaction observed), which decreased with BMI and increased with age. In the overall cohort, compared to normal weight status (BMI 18.5–24.9 kg/m2 ), death odds ratios for underweight (BMI < 18.5), overweight (BMI 25.0–29.9) and obesity (BMI ≥30) were 1.35 (95%CI, 1.20–1.53), 0.87 (95%CI, 0.77–0.97) and 0.73 (95%CI, 0.62–0.86), respectively. In patients assessed within 72 hours since admission, the associations were comparable: for underweight, 1.48 (95%CI, 1.11–1.96); for overweight, 0.80 (95%CI, 0.65–0.97); for obesity, 0.75 (95%CI, 0.58–0.96). Conclusion In adult hospitalized patients BMI and age are independent predictors of in-hospital mortality. Low body weight is confirmed being a risk factor for death as in the general population, while overweight and obesity appear protective conditions. In the hospital setting, the use of normal weight status as reference low-risk category could also be challenged.
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