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1The Critical Care Communications • A monthly newsletter of Indian Society of Critical Care Medicine

ommunications

riticalareCCC A monthly newsletter of

Indian Society of Critical Care Medicine

The

Volume 4.3 • May-June, 2009

• CRITICARE-2010 .......1, 2, 7, 8

• Message from the Editor .......3

• Message from the President ...4

• IndICAPS Study ................ 5-6

• Upcoming Critical Care

Medicine Calendar .......... 9-10

• Guidelines for the provision

and assessment of nutrition

support therapy in the adult

critically ill patient ............. 11-13

• Journal Scan ........................14-15

• Delhi Critical Care

Symposium 2009 .....................16

In this issue

A monthly newsletter of Indian Society of Critical Care Medicine • The Critical Care Communications2


MeSSAge froM The edITorDear Friends,

You must be aware that the INDICAPS, the Indian ICU Case mix and practice patterns

study is underway. More than 200 ICUs have already registered for this landmark

large scale survey undertaken by the Indian Society of Critical Care Medicine. This

will generate information about ICU patients and practices in our country. If you

have not registered yet, please do so now. Please log on to http://isccm.org/ISCCM/

Instituteregistration.aspx and give information about your ICU in the relevant

sections. We will be able to get truly representative data only if everyone contributes

whole heartedly and gives authentic information. Dr. J. Divatia has discussed this

endeavor in some detail in this bulletin.

The controversy over the use of corticosteroids in reducing mortality in ARDS

continues. A new meta-analysis suggests that steroids reduce both mortality and

morbidity. This new study has also suggested that steroids are an effective treatment

for ALI and ARDS. However the mortality benefits still require an adequately

powered trial. You can read about this and other issues in the Journal Scan. Nutrition

significantly impacts outcome in the critically ill. New Nutrition guidelines have

been published in CCM. The summary of the guidelines are also published in this

issue.

The next annual 16th Critical Care Congress of Indian Society of Critical Care

Medicine is being held in Hyderabad from 10th to 14th Feb, 2010. You will get some

preliminary information about the Congress in this bulletin. There will be workshops

on Bronchoscopy, Critical Care Neuro Monitoring ,Hemodynamic Monitoring,

SIM man based scenarios including trauma, BLS & ACLS, Extra Corporeal blood

purification - basic and advanced, Imaging in CCM - basic and advanced, FCCS -

Instructor / Provider Course and two days pre conference CME course. You can

register now on http://www.criticare2010.org/

Let me also take this opportunity to invite you to the “DCCS 2009”, Delhi Critical

Care Symposium, 8th Annual Conference of Delhi & NCR Chapter of India Society

of Critical Care Medicine being held from 3rd to 6th September 2009 at The Lalit,

Barakhamba Road, New Delhi this year. For more details please visit website

www.delhiccs.org

With best wishes!

dr. rajesh ChawlaPRESIDENT ELECT

edITorIAl offICe

dr. rajesh ChawlaSenior Consultant, Respiratory & Critical Care Medicine, Indraprastha Apollo Hospitals, Room No. 4162, 1st Floor, Gate No. 10, New Delhi - 110076 Telefax : 011-2682 5586emails : [email protected]

Published By : IndIAn SoCIeTy of CrITICAl CAre MedICIne, Bldg. No.3, No.12, 5th Floor, Navjivan Commercial Premises Co-op. Society Ltd., Dr. D. Bhadkamkar Road, Mumbai Central, Mumbai 400 008. • Tel.: (022) 6526 8504 • Telefax: (022) 2305 4843

Be a part of

INDICAPSIndian ICU Case mix And Practice patterns Study (IndICAPS)For registration Log on to http://

www.isccm.org/ISCCM/Instituteregistration.aspx


Dear Friends

We meet once again in another issue of Critical Care Communications. Through this newsletter, I am able to keep you informed of the various activities and initiatives in which your society has been involved. My message in this issue will be dedicated to one of the largest critical care research initiatives taken in our country, the INDian Intensive care CAse mix and Practice patterns Study, or INDICAPS.

INDICAPS is the first large scale, multicentre survey launched by the ISCCM. The aim is to gather information about ICUs, patients in ICUs, the types and severity of illness, monitoring and therapeutic modalities used, types of infections, and other such data. We have no authentic, national data and this is our attempt to generate such data. Over the past few issues, I have been urging members to register their ICUs for this study, and I am delighted that over 230 ICUs have registered for this study. Your enthusiasm is unparalleled and encouraging, but we must now move on to the next step.

We plan to collect data on 1-2 days this year, and on 3-4 other days next year. You have to give data for all patients in the ICU on that particular day only. On the study day, you have to fill one ICU form for your ICU, and one patient form per patient that is in your ICU on that day. Sample forms are printed in this newsletter.

This cross-sectional design makes it easy to follow, and spares busy clinicians the effort of maintaining data daily throughout the ICU stay of every patient. It does require that you spare time for us on that one day. This will generate powerful and imortant data on Indian critical care.

MeSSAge froM The PreSIdenTdr. J.V. divatiaProfessor & In-Charge, Critical Care Service, Tata Memorial Hospital Mumbai

In the period that ICUs were registering through our website or by letter, a steering committee was preparing a draft proforma, and the first draft was discussed during the annual conference at Agra. The proforma has been finalised. This will be hosted on the internet, and members can access it through the ISCCM website. The web design of the data entry form is being done by professional developers. This will have help features, definitions and other features to make data entry a painless and simple process. The database of ICUs and co-ordinators is being finalized. What will happen next?

1. In the next few weeks, you will receive an SMS and email confirming your participation in INDICAPS, and giving you an User ID and password for the study

2. Go to the ISCCM website and log in using the given user ID and password. This will allow you to verify your ICU details, in case any changes have taken place since the time you registered. In particular, please make sure your mobile number and email id are correctly entered, and that you give the name, mobile number and email of an alternative contact person for this study.

3. The proforma and instructions will be displayed on the internet for you to download. You can use this to obtain approval from your hospital ethics committee. If your hospital does not have an ethics committee, please indicate this by ticking the appropriate box when you verify your ICU details at first login.

4. The preferred mode of data entry is thru the website. If you do not have reliable internet access, please write to me, we will work out an alternative paper format.

5. Once we are ready at our end, we will announce the first date for data collection on the website, and by SMS and email

6. Log on to the data entry form using your login details. Good luck!

This study will also pose formidable challenges. The biggest one is to communicate effectively with so many investigators. Hopefully, with modern technology, using SMS, email and the internet, as well as traditional methods including this newsletter, we will reach out to most members. A country like India has a wide diversity of types of ICUs, patients and practices, and it is this diversity that we wish to capture. So whether your ICU is large or small, 5-star hospital or 5-bed nursing home, urban or rural., full or empty, overstaffed or under-staffed, surgical or medical or cardiac or neuro, do not hesitate to join this study. Our diversity is our biggest challenge, but it also makes the entire study fascinating and worth doing. If everyone was the same, life would be very boring!

Lastly, the success of this venture finally depends on YOUR EFFORT. Our initial enthusiasm must now be backed by disciplined and honest reporting of data. We depend on you to fill in data on your ICU and your patients, to fill it in accurately, consistently and in a timely fashion. If you are able to sacrifice a little time and devote it to this study on one particular day, we can do it. Successful completion of the study will silence skeptics even amongst us who doubt our ability to generate authentic information. We will have data for ourselves and we will have shown the world that India can take on a huge challenge, and succeed.

Yes, We Can!

Till we meet again

Dr. JV Divatia

IndICAPS : ISCCM’S fIrST nATIonAl MulTICenTre SurVey :

Log on to http://www.isccm.org/ISCCM/Instituteregistration.aspx


ISCCM Center No. ......................................... Date of data collection .............. /............../ 2009

Type of ICU: Mixed Medical + Surgical Noncardiac Surgical Medical Medical + Coronary Coronary care Neurosurgical

Neurological Surgical cardiac Transplant Trauma Other

How many beds do you have in the ICU?

Does your hospital have a step-down or Intermediate Care or High Dependency Unit?

At 1200 on the study day:

• How many beds are occupied? ....................................................................................................................................................................................................................................

• How many patients are ventilated? ..............................................................................................................................................................................................................................

Noninvasive Via ETT / Tracheostomy

• How many have head elevation 30-45degrees? ...........................................................................................................................................................................................................

• How many nurses are present in the ICU? ...................................................................................................................................................................................................................

• How many doctors (ICU, not visiting consultants) are present in the ICU? ...............................................................................................................................................................

• How many patients have an arterial line? ....................................................................................................................................................................................................................

• How many patients have a central venous line? .........................................................................................................................................................................................................

• How many patients have a cardiac output monitoring device attached? (e.g. PA catheter, PiCCO, Flotrac, etc) .....................................................................................................

• How many patients are receiving or scheduled for renal replacement therapy? .......................................................................................................................................................

• How many patients are being enterally fed? ................................................................................................................................................................................................................

By mouth By tube feeding

• How many patients are receiving thromboprophylaxis? .............................................................................................................................................................................................

Mechanical Pharmacological

• How many patients are receiving intravenous sedation? ............................................................................................................................................................................................

• How many patients are receiving stress ulcer prophylaxis? .......................................................................................................................................................................................

• How many patients are receiving intravenous antibiotics? ........................................................................................................................................................................................

• How many patients are having physical restraints? ....................................................................................................................................................................................................

In these 24 hrs

• How many patients have been cared for in your ICU? ................................................................................................................................................................................................

• How many new admissions, discharges, and deaths did the unit have?

.................... Admissions .................... Discharges from the unit .................... Deaths

Indian ICu Case mix And Practice patterns Study (IndICAPS)ICu forM

(one form for ICu on the study day)

Indian ICu Case mix And Practice patterns Study (IndICAPS)ICu forM

(one form for ICu on the study day)

ISCCM Center No. ......................................... Patient No. ...........................................................

Date of data collection .............. /............../ 2009 Date of ICU admission .............. /............../ 2009 Date of hospital admission .............. /............../ 2009

Age ........................yrs Sex: Male Female Weight: ........................Kg

Type of admission: Medical Surgical (Directly from OT/Recovery)

Elective Emergency Site / type of surgery ................................... Trauma

Is this patient self paying payment by employer private health insurance

Admission source: Home Ward of same hospital Casualty / Emergency Department Ward of other hospital ICU of other hospital

Others, please specify ........................................................................................ From same city/ town From other city /town

If from other town, distance from your ICU ...................................................... kms

Reason for ICU admission (Tick all that apply)

Basic & observational Cardiovascular Digestive Hematological Hepatic Metabolic Neurological Poisoning Renal Respiratory Trauma Other

APACHE III admission Diagnosis (Use SINGE best APACHE III diagnostic code) ............................................................................................................................................................

Comorbidities COPD Cancer Therapy Metastatic cancer Hematologic cancer Insulin dependent diabetes mellitus Heart failure (NYHA III)

Heart failure (NYHA IV) Chronic renal failure HIV infection Cirrhosis AIDS Immunosuppression Steroid therapy

Was the patient admitted to ICU with suspected / confirmed infection? Yes NO

If infection suspected / confirmed, was it (tick all that apply)

Malaria Leptospirosis Dengue fever Scrub typhus Bacterial Viral Fungal Other

Does the patient have suspected / confirmed infection today? Yes NO

Malaria Leptospirosis Dengue fever Scrub typhus Bacterial Viral Fungal Other

Did the infection develop in ICU? Yes NO

If infection was confirmed (Enter microorganism codes as per appendix)

Microorganism 1 ................................ 2 ................................ 3 ................................ 4 ................................

What antibiotics is the patient receiving today (Enter antibiotic code as per appendix) 1 ................................ 2 ................................ 3 ................................ 4 ................................

Is the patient receiving anti-malarials today ? Yes No.

If yes, is he getting Quinine artesunate chloroquin

At any time during ICU stay did the patient have

Severe Sepsis Yes NO Septic Shock Yes NO Low dose steroids (for septic shock) Yes NO Activated Protein C Yes NO

Did this patient come to the ICU after poisoning? Yes NO, If yes

Organophosphorus poisoning Organochlorine poisoning Aluminium phosphide poisoning Rat poisoning Sedative overdose Tricylic antidepressant overdose

Heroin / Cocaine or recreational drug overdose Unknown Other, please specify...............................................................................................................................................

Today has this patient received

Normal Saline or Ringer lactate at rate more than 500 mL/Hr Hemaccel Gelofusine Any starch solutions (e.g. Voluven, Hestar, Haes-steril, etc)

Whole Blood / packed cells Fresh Frozen Plasma Platelets Albumin

Today did this patient have

Hourly urine output monitoring (measured every hour) Yes NO

Invasive Arterial blood Pressure Yes NO If yes Site Code ...........................................

Central Venous Pressure Yes NO If yes Site Code ...........................................

Cardiac output monitoring Yes NO If yes Monitor type Code ............................

Intraaortic Balloon Pump Yes NO



Indian ICu Case mix And Practice patterns Study (IndICAPS)

Indian ICu Case mix And Practice patterns Study (IndICAPS) (outcome)

ISCCM Center no. ......................................... Patient no. ...........................................................

fill in the following details for this patient today (only fill if done on that day)

Cardiovascular system

Lactate (max) _ _ _ . _ _ mmol/L

Was Central Venous Oxygen Saturation measured? Yes No If yes, (min) ..................... % (max) ..................... %

Was Stroke Volume Variation measured? Yes No If yes (min) ..................... % (max) ..................... %

Noradrenaline Yes No if yes, dose (max) _ _ . _ _ _ μg/kg/min

Dopamine Yes No if yes, dose (max) _ _ . _ _ _ μg/kg/min

Adrenaline Yes No if yes, dose (max) _ _ . _ _ _ μg/kg/min

Dobutamine Yes No if yes, dose (max) _ _ . _ _ _ μg/kg/min

Other inotropes / vasopressors .............................................................. dose .......................................... μg/kg/min

for APAChe II calculations

Heart rate (min) ........................ (max) ........................ bpm Core body temperature (min) _ _ _ . _ _ (max) _ _ _ . _ _ ° C

Systolic blood pressure (min) ........................ (max) ........................ mmHg Mean arterial pressure (min) ........................ mmHg

Diastolic blood pressure (min) ........................ (max) ........................ mmHg Respiratory Rate (min) ........................ (max) ........................ bpm

Glasgow Coma Score (worst) Eye opening ............. (1-4) Verbal Response ............. (1-5) Motor Response ............. (1-6) Total ......................................

Blood urea (max) _ _ _ . _ _ mg/dL Sr. creatinine (max) _ _ _ . _ _ mg/dL

Urine output ....................... mL/24hours Hemodialysis Yes No CRRT Yes No

Hemoglobin ........................ gm/dL INR (worst) _ _ . _ _ _ PT (worst) ............................ secs

Leukocytes (min) ........................ (max) ........................... 103/mm3 Platelets (min) .......................... 103/mm3

Serum potassium (min) _ _ _ . _ _ _ (max) _ _ _ . _ _ _ mmol/L Serum sodium (min) ..................... (max) ..................... mmol/L

Total bilirubin (max) _ _ _ . _ _ mg/dL Serum bicarbonate (min) .................... mmol/L

pH _ _ ._ _ _ PaO2 (min) ..................... mmHg (max) ............................. mmHg FiO2 (min) ........................ mmHg (max) ........................... mmHg

respiratory system

Mechanical ventilation Yes No Non-Invasive Ventilation Yes No

If the patient is ventilated, reason for ventilation is

OP poisoning Snake bite GB syndrome or other neuromuscular disease Major Trauma or surgery COPD Pneumonia ARDS

Cardiac failure Severe sepsis Other, Please specify .................................................................................................

Endotracheal intubation Yes No If yes, Route Oral Nasal

Tracheostomy Yes No If Yes, Surgical Percutaneous

At 1200 noon, what were the ventilator settings?

Mode of MV being used Pressure control Volume control CMV Assist control SIMV SIMV + Pressure Support

Pressure Support PRVC Other, please specify .................................................................................................

Tidal Volume ..................... mL PEEP ................. cmH2O Plateau Pressure ................. cmH2O

Peak Pressure (min) ................... (max) ................... cmH2O Respiratory rate ................... /min

Patient position Flat Head low Semirecumbent

At any time today did the patient have

Prone position Yes No

Methylprednisolone or other steroid Yes No If yes, Dose ........................ mg Day no. ........................

feeding

Enteral Yes No If yes, Route code ....................................................

What is being fed to the patient?

Cooked food Blendarised food Prepared from commercial powders

If the patient is being fed via tube, is he receiving

Continuous feed Intermittent bolus feeds Prokinetics

Parenteral Nutrition Yes No

Central nervous system

ICP monitoring Yes No

Miscellaneous

Stress ulcer prophylaxis Yes No

If yes,

H2 blocker Proton Pump Inhibitor Sucralfate

DVT prophylaxis Yes No

If yes

TEDS stockings Intermittent sequential compression pump Low molecular weight heparin unfractionated heparin

Was this patient transported out of the ICU today? Yes No If yes

Within the same hospital Outside the hospital

ISCCM Center no. ......................................... Patient no. ...........................................................

Final diagnosis ....................................................................................................................................................

Duration of ventilation .................................... days

Date of ICU discharge ................. / ................. / 2009 Time ................. : .................

Survival Status at ICU discharge Dead Alive

If the patient has died in ICU, did he die while on

Full treatment Full treatment but no CPR

Limitation or non escalation of therapy Withdrawal of life sustaining therapy

Was this patient a LAMA (Left against medical advice) or DAMA (disharged against medcal advice) discharge ? Yes No

If discharged alive from ICU, the patient was discharged to

Ward Intermediate unit Other ICU Other hospital Home Other, please specify ......................................................................................

hospital outcome

Date of hospital discharge ................ / ................ / 2009

Survival status at hospital discharge Dead Alive





July 12-13, 2009

1. fundamentals of Critical Care ultrasoundHilton San Francisco Hotel, San Francisco, California, USAE-mail : [email protected] • Website : www.sccm.orgPhone:- +1847 827-6888 • Fax:- +1847 493-6444

July 12-18, 2009

2. Society of Critical Care Medicine Adult and Pediatric review CoursesHilton San Francisco Hotel, San Francisco, California, USAE-mail : [email protected] • Website : www.sccm.orgPhone:- +1847 827-6888Fax:- +1847 493-6444

July 13, 2009

3 rapid response System TrainingHilton San Francisco Hotel, San Francisco, California, USAWebsite : www.sccm.orgPhone:- +1847 827-6888Fax:- +1847 493-6444

July 15 – 17, 2009

4. The 3rd Annual Critical Care Symposia 2009London, United KingdomE-mail : [email protected] Website : www.mahealthcareevents.co.uk/cgibin/go.pl/conferences/detail.html?conference_uid=91Phone: +44 (0) 20 7501 6762Fax: +44 (0) 20 7733 8174

August 25-29, 2009

5. 4th International Multidisciplinary Congress on Intensive and Critical Care MedicineSchool of Medicine, Instituto Politecnico NacionalMexico City, MexicoE-mail : [email protected] Website: http://www.amecrit.org

August 29th - September 1st 2009

6. 31st european Society for Clinical nutrition and Metabolism (eSPen) CongressMesse Wien Exhibition & Congress CentreMesseplatz 1021, Vienna, Austria E-mail: [email protected]: http://www.espen.org/vienna/default.htmlPhone: (+41) 22 33 99 627 Fax: (+41) 22 33 99 601

August 28th - September 1st, 2009

7. 10th World Congress of the World federation of Societies of Intensive and Critical Care MedicineFlorence, ItalyE-mail: [email protected]: www.wfsiccm-florence2009.it Phone: +39 040 660352 Fax: +39 040 660353 - 660352

upcoming Critical Care Meetings Calendar


September 4-6, 2009

8. delhi Critical Care Symposium -2009The 8th Annual Conference of Indian Society of Critical Care Medicine The Lalit, Barakhamba Road, New DelhiE-mail: [email protected] • website: www.delhiccs.orgPhone:- 011-26825586 • Fax:- 011-26825586

October 25-29, 2009

9. Critical Care Canada forumToronto, CanadaE-mail : [email protected] : www.criticalcarecanada.comPhone: (519) 263-5050 / 888-527-3434Fax: (519) 263-2936 / 888-527-2905

October 29-31, 2009

10. AnZICS/ACCCn/Intensive Care ASM ConferencePerth Convention Exhibition Centre, Perth, AustraliaE-mail : [email protected] : www.intensivecareasm.com.auPhone: (08) 9389 1488 • Fax: (08) 9389 1499

October 11-14, 2009

11. 22nd Annual Congress european Society of Intensive Care Medicine“Patient Safety and Quality of Care in Intensive care Medicine”Vienna, AustriaE-mail : [email protected] • Website : www.esicm.orgPhone: +49 (0)30 246 03 319 • Fax: +49 (0)30 246 03 267

November 11-14, 2009

12. Sepsis 2009: An International SymposiumBeurs van Berlage, Damrak 277, 1012 Zj AmsterdamWebsite : http://www.sepsisforum.org/Phone: +44 (0) 1794 511331/2 • Fax: +44 (0) 1794 511455

January 9-13, 2010

13. 39th Annual Critical Care CongressMiami Beach, Florida, USA.E-mail: [email protected] • Website : www.sccm.orgPhone: +1 847 827-6869 • Fax: +1 847 827-6886

February 10-14, 2010

14. Criticare 2010International Critical Care Congress & 16th Annual Conference of Indian Society of Critical Care Medicine6-3-248//1, Indralok Complex, 304, A Block 3rd Floor Road No. 1, Banjara hills, Hyderabad - 500034E-mail: [email protected] • Website : criticare2010.orgPhone: +91 9959681858

September 18-22, 2010

15. erS Annual Congress 2010Fira de Barcelona Gran Vía Avenida Juan Carlos 1º, 5808908 L´Hospitalet (Barcelona), SpainE-mail: [email protected] • Website : http://www.erscongress2010.orgPhone: +34 932 332 297

upcoming Critical Care Meetings Calendar


guidelines for the provision and assessment of nutrition support therapy in the adult critically ill

patient

robert g. Martindale, Md;

Stephen A. McClave, Md;

Vincent W. Vanek, Md; et al.

Crit Care Med, May 2009;

37(5):1757-1761

definitionsGrading system used for these guidelines

a. Supported by at least two level I investigations

b. Supported by one level I investigation

c. Supported by level II investigations only

d. Supported by at least two level III investigations

e. Supported by level IV or level V evidence

Level of evidence

I. Large, randomized trials with clearcut results; low risk of false-positive (alpha) error or falsenegative (beta) error

II. Small, randomized trials with uncertain results; moderate to high risk of false-positive (alpha) and/or false-negative (beta) error

III. Nonrandomized, contemporane-ous controls

IV. Nonrandomized, historical controls

V. Case series, uncontrolled studies, and expert opinion

Initiate enteral feedinga. Traditional nutrition assessment

tools are not validated in critical care (albumin, prealbumin, and anthropometry). Before initiation of feedings, assessment should include evaluation of weight loss and previous nutrient intake before admission, level of disease function of the gastrointestinal tract.

b. Nutrition support therapy in the form of EN should be initiated in the critically ill patient who is unable to maintain volitional intake.

c. EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy.

d. Enteral feeding should be started early within the first 24–48

hours following admission. The feedings should be advanced toward goal over the next 48–72 hours.

e. In the setting of hemodynamic compromise (patients requiring significant hemodynamic support, including high-dose catecholamine agents, alone or in combination with large volume fluid or blood product resuscitation to maintain cellular perfusion), EN should be withheld until the patient is fully resuscitated and/or stable.

f. In the ICU patient population, neither the presence nor the absence of bowel sounds and evidence of passage of flatus and stool is required for the initiation of enteral feeding.

g. Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. Withholding of enteral feeding for repeated high gastric residual volumes alone may be a sufficient reason to switch to small bowel feeding (the definition for high gastric residual volume is likely to vary from one hospital to the next, as determined by individual institutional protocol) (see No. 4 of Monitoring Tolerance and Adequacy of EN section for recommendations on gastric residual volumes, identifying high-risk patients, and reducing chances for aspiration).

When to use Pn

1. If early EN is not feasible or available over the first 7 days following admission to the ICU, no nutrition support therapy (standard therapy) should be provided. In the patient who was previously healthy before critical illness with no evidence of proteincalorie malnutrition, use of PN should be reserved

and initiated only after the first 7 days of hospitalization.

2. If there is evidence of protein-calorie malnutrition at admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation.

3. If a patient is expected to undergo major upper gastrointestinal surgery and EN is not feasible, PN should be provided under very specific conditions:

a. If the patient is malnourished, PN should be initiated 5–7 days preoperatively and continued into the postoperative period.

b. PN should not be initiated in the immediate postoperative period, but should be delayed for 5–7 days.

c. PN therapy provided for duration of <5–7 days would be expected to have no outcome effect and may result in increased risk to the patient. Thus, PN should be initiated only if the duration of therapy is anticipated to be >7 days.

4. Ongoing assessment of adequacy of protein provision should be performed. The use of additional modular protein supplements is a common practice, as standard enteral formulations tend to have a high nonprotein calorie:nitrogen ratio. In patients with body mass index (BMI) <30, protein requirements should be in the range of 1.2–2.0 g/kg actual body weight per day, and may likely be even higher in patients with burn or multiple trauma.

5. In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended. For all classes of obesity where BMI is >30, the goal of the EN regimen should not exceed 60% to 70% of target energy requirements or 11–14 kcal/kg actual body weight/day (or 22–25 kcal/kg ideal body weight/day). Protein should be

A monthly newsletter of Indian Society of Critical Care Medicine • The Critical Care Communications12provided in a range >2.0 g/kg ideal body weight/day for class I and class II patients (BMI 30– 40), >2.5 g/kg ideal body weight/day for class III (BMI >40). Determining energy requirements is discussed elsewhere.

dosing of enteral feeding

1. The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy (Grade C). Energy requirements may be calculated by predictive equations or measured by indirect calorimetry. Predictive equations should be used with caution, as they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient. In the obese patient, the predictive equations are even more problematic without availability of indirect calorimetry.

2. Efforts to provide>50% to 65% of goal calories should be made to achieve the clinical benefit of EN over the first week of hospitalization.

3. If unable to meet energy requirements (100% of target goal calories) after 7–10 days by the enteral route alone, consider initiating supplemental PN. Initiating supplemental PN before this 7–10-day period in the patient already on EN does not improve outcome and may be detrimental to the patient.

Monitoring Tolerance and Adequacy of en

1. In the ICU setting, evidence of bowel motility (resolution of clinical ileus) is not required to initiate EN in the ICU.

2. Patients should be monitored for tolerance of EN (determined by patient complaints of pain and/or distention, physical examination, passage of flatus and stool, abdominal radiographs). Inappropriate cessation of EN should be avoided. Holding EN for gastric residual volumes <500 mL in the absence of other signs of intolerance should be avoided. Making the patient nil per os surrounding the time of diagnostic tests or procedures should be minimized to prevent inadequate delivery of nutrients and prolonged periods of ileus.

Ileus may be propagated by nil per os status.

3. Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented.

4. Patients placed on EN should be assessed for risk of aspiration. Steps to reduce risk of aspiration should be used The following measures have been shown to reduce risk of aspiration:

a. In all intubated ICU patients receiving EN, the head of the bed should be elevated 30°– 45°.

b. For high-risk patients or those shown to be intolerant to gastric feeding, delivery of EN should be switched to continuous infusion.

c. Agents to promote motility, such as prokinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan), should be initiated where clinically feasible.

d. Diverting the level of feeding by postpyloric tube placement should be considered.

e. Use of chlorhexidine mouthwash twice a day should be considered to reduce risk of ventilator-associated pneumonia.

5. Blue food coloring and glucose oxidase strips, as surrogate markers for aspiration, should not be used in the critical care setting.

6. Development of diarrhea associated with enteral tube feedings warrants further evaluation for etiology

Selection of Appropriate enteral formulation

1. Immune-modulating enteral formulations (supplemented with agents, such as arginine, glutamine, nucleic acid, omega-3 fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), being cautious in patients with severe sepsis (for surgical ICU patients Grade A) (for medical ICU patients Grade B). ICU patients

not meeting criteria for immune- modulating formulations should receive standard enteral formulations.

2. Patients with acute respiratory distress syndrome and severe acute lung injury should be placed on an enteral formulation characterized by an anti-inflammatory lipid profile (i.e., omega- 3 fish oils, borage oil) and antioxidants.

3. To receive optimal therapeutic benefit from the immune-modulating formulations, at least 50% to 65% of goal energy requirements should be delivered.

4. If there is evidence of diarrhea, soluble fiber-containing or small peptide formulations may be used.

Adjunctive Therapy

1. Administration of probiotic agents has been shown to improve outcome (most consistently by decreasing infection) in specific critically ill patient populations involving transplantation, major abdominal surgery, and severe trauma. No recommendation can currently be made for use of probiotics in the general ICU population because of a lack of consistent outcome effect. It seems that each species may have different effects and variable impact on patient outcome, making it difficult to make broad categorical recommendations. Similarly, no recommendation can currently be made for use of probiotics in patients with severe acute necrotizing pancreatitis, based on the disparity of evidence in the literature and the heterogeneity of the bacterial strains used.

2. A combination of antioxidant vitamins and trace minerals (specifically including selenium) should be provided to all critically ill patients receiving specialized nutrition therapy.

3. The addition of enteral glutamine to an EN regimen (not already containing supplemental glutamine) should be considered in burn, trauma, and mixed ICU patients.

4. Soluble fiber may be beneficial for the fully resuscitated, hemodynamically stable critically ill patient receiving


EN who develops diarrhea. Insoluble fiber should be avoided in all critically ill patients. Both soluble and insoluble fiber should be avoided in patients at high risk for bowel ischemia or severe dysmotility.

When Indicated, Maximize efficacy of Pn

1. If EN is not available or feasible, the need for PN therapy should be evaluated (see recommendations No. 1, 2, and 3 of When to Use PN section and No. 3 of Dosing of Enteral Feeding section). If the patient is deemed to be a candidate for PN, steps to maximize efficacy (regarding dose, content, monitoring, and choice of supplemental additives) should be used.

2. In all ICU patients receiving PN, mild permissive underfeeding should be considered, at least initially. Once energy requirements are determined, 80% of these requirements should serve as the ultimate goal or dose of parenteral feeding. Eventually, as the patient stabilizes, PN may be increased to meet energy requirements. For obese patients (BMI >30), the dose of PN with regard to protein and caloric provision should follow the same recommendations given for EN in recommendation.

3. In the first week of hospitalization in the ICU, when PN is required and EN is not feasible, patients should be given a parenteral formulation without soy-based lipids.

4. A protocol should be in place to promote moderately strict control of serum glucose when providing nutrition support therapy. A range of 110–150 mg/dL may be most appropriate.

5. When PN is used in the critical care setting, consideration should be given to supplementation with parenteral glutamine.

6. In patients stabilized on PN, periodically repeat efforts should be made to initiate EN. As tolerance improves and the volume of EN calories delivered increases, the amount of PN calories supplied should be reduced. PN should not be terminated until >60% of target energy requirements are being delivered by the enteral route.

Pulmonary failure

1. Specialty high-lipid low-carbohydrate formulations designed to manipulate the respiratory quotient and reduce CO2 production are not recommended for routine use in ICU patients with acute respiratory failure (this is not to be confused with the recommendation No. 2 of Selection of Appropriate Enteral Formulation section for acute respiratory distress syndrome/ acute lung injury).

2. Fluid-restricted calorically dense formulations should be considered for patients with acute respiratory failure.

3. Serum phosphate levels should be monitored closely, and replaced appropriately when needed.

renal failure

1. ICU patients with acute renal failure or acute kidney injury should be placed on standard enteral formulations, and standard ICU recommendations for protein and calorie provision should be followed. If significant electrolyte abnormalities exits or develop, a specialty formulation designed for renal failure.

2. Patients receiving hemodialysis or continuous renal replacement therapy should receive increased protein, up to a maximum of 2.5 g/kg/day. Protein should not be restricted in patients with renal insufficiency as a means to avoid or delay initiation of dialysis therapy.

hepatic failure

1. Traditional assessment tools should be used with caution in patients with cirrhosis and hepatic failure, as these tools are less accurate and less reliable because of complications of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia.

2. EN is the preferred route of nutrition therapy in ICU patients with acute and/or chronic liver disease. Nutrition regimens should avoid restricting protein in patients with liver failure.

3. Standard enteral formulations should be used in ICU patients with acute and chronic liver disease. The branched chain

amino acid formulations should be reserved for the rare encephalopathic patient who is refractory to standard therapy with luminal-acting antibiotics and lactulose.

Acute Pancreatitis

1. At admission, patients with acute pancreatitis should be evaluated for disease severity. Patients with severe acute pancreatitis should have a nasoenteric tube placed and EN initiated as soon as fluid volume resuscitation is complete.

2. Patients with mild to moderate acute pancreatitis do not require nutrition support therapy (unless an unexpected complication develops or there is failure to advance to oral diet within 7 days).

3. Patients with severe acute pancreatitis may be fed enterally by the gastric or jejunal route.

4. Tolerance to EN in patients with severe acute pancreatitis may be enhanced by the following measures:

a) Minimizing the period of ileus after admission by early initiation of EN.

b) Displacing the level of infusion of EN more distally in the gastrointestinal tract.

c) Changing the content of the EN delivered from intact protein to small peptides and long-chain fatty acids to medium-chain triglycerides or a nearly fat-free elemental formulation.

d) Switching from bolus to continuous infusion.

5. For the patient with severe acute pancreatitis, when EN is not feasible, use of PN should be considered. PN should not be initiated until after the first 5 days of hospitalization.

nutrition Therapy end-of-life Situations

1. Specialized nutrition therapy is not obligatory in cases of futile care or end-of-life situations.

2. The decision to provide nutrition therapy should be based on effective patient/family communication, realistic goals, and respect for patient autonomy.


Journal Scan dr. Sudha Kansal MD, IDCC

dr. Prashant nasa MD, IDCC

Dept of Critical Care Medicine,Indraprastha Apollo Hospitals, New Delhi

Pain Management within the Palliative and end-of-life

Care experience in the ICu

Serum lactate is associated with mortality in severe sepsis independent of organ failure

and shock

evolving role of early antifungals in the adult

intensive care unit

A systematic review on clinical benefits of continuous

administration of [beta]-lactam antibiotics

use of corticosteroids in acute lung injury and acute

respiratory distress syndrome: A systematic review and

meta-analysisnonthyroidal Illness Syndrome and Prolonged Mechanical Ventilation in

Patients Admitted to the ICu

Richard A. Mularski, Kathleen Puntillo, Basil Varkey, et al.

Chest, June 2009; 135(5):1360-1369

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Mark E. Mikkelsen, Andrea N. Miltiades, Munish Goyal et al.

Crit Care Med, May 2009; 37(5):1670-1677Serum lactate is a potentially useful biomarker to risk-stratify patients with severe sepsis; however, it is plausible that elevated serum lactate is simply a manifestation of clinically apparent organ dysfunction and/or shock (i.e., refractory hypotension).

To test whether the association between initial serum lactate level and mortality in patients presenting to the emergency department (ED) with severe sepsis is independent of organ dysfunction and shock.

This is a single-center cohort study. The primary outcome was 28-day mortality and the risk factor variable was initial venous lactate (mmol/L), categorized as low (<2), intermediate (2-3.9), or high (>=4). Potential covariates included age, sex, race, acute and chronic organ dysfunction, severity of illness, and initiation of early goal-directed therapy. Multivariable logistic regression analyses were stratified on the presence or absence of shock.

The ED of an academic tertiary care center from 2005 to 2007 eight hundred thirty adults admitted with severe sepsis in the ED.

Mortality at 28 days was 22.9% and median serum lactate was 2.9 mmol/L. Intermediate (odds ratio {OR = 2.05, p = 0.024) and high serum lactate levels (OR = 4.87, p < 0.001) were associated with mortality in the nonshock subgroup. In the shock subgroup, intermediate (OR = 3.27, p = 0.022) and high serum lactate levels (OR = 4.87, p = 0.001) were also associated with mortality. After adjusting for potential confounders, intermediate and high serum lactate levels remained significantly associated with mortality within shock and nonshock strata.

Initial serum lactate was associated with mortality independent of clinically apparent organ dysfunction and shock in patients admitted to the ED with severe sepsis. Both intermediate and high serum lactate levels were independently associated with mortality.

Simon W. Lam, Gregory A. Eschenauer & Peggy L. Carver

Crit Care Med, May 2009; 37(5): 1580-1593Invasive candidiasis (IC) is associated with significant morbidity and mortality in critically ill patients. This, in conjunction with difficulties in diagnosis, underscores the need for novel treatment strategies based on the identification of significant risk factors for IC.

To review the evidence surrounding the use of early antifungals in critically ill adult patients and to present concise and specific recommendations for different early treatment strategies for IC.

Pubmed search from 1966 to July 2008 using the search terms "antifungals, critical care, prophylaxis, preemptive therapy, and empiric therapy." Examined all relevant peer-reviewed original articles, meta-analyses, guidelines, consensus statements, and review articles.

The use of early antifungal therapy should be reserved for patients with a high risk (10% to 15%) of developing IC. Despite a large number of articles published on this topic, there is no single predictive rule that can adequately forecast IC in critically ill patients. Until further prospective validation of existing data is completed, clinicians should assess patients on a case-by-case basis and determine the need for early antifungal treatment strategies based on frequent evaluations of risk factors and clinical status.

Jason A. Roberts, David Paterson, Kwok M. Ho, et al.

Crit Care Med, June 2009; 37(6): 2071-2078The clinical benefits of extended infusion or continuous infusion of [beta]-lactam antibiotics remain controversial. We systematically reviewed the literature to determine whether any clinical benefits exist for administration of [beta]-lactam antibiotics by extended or continuous infusion.

PubMed (January 1950 to November 2007), EMBASE (1966 to November 2007), and the Cochrane Controlled Trial Register were searched (updated November 2007).

Randomized controlled trials (RCTs) were meta-analyzed, and observational studies were described by two unblinded reviewers.

A total of 846 patients from eligible prospective randomized controlled studies were included in the meta-analysis. Two observational studies were deemed appropriate for description.

A meta-analysis of prospective RCTs was undertaken using Review Manager. Among a total of 59 potentially relevant studies, 14 RCTs involving a total of 846 patients from nine countries were deemed appropriate for meta-analysis. The use of continuous infusion of a [beta]-lactam antibiotic was not associated with an improvement in clinical cure (n = 755 patients; odds ratio: 1.04, 95% confidence interval: 0.74-1.46, p = 0.83, I2 = 0%) or mortality (n = 541 patients; odds ratio: 1.00, 95% confidence interval: 0.48-2.06, p = 1.00, I2 = 14.8%). All RCTs except one used a higher antibiotic dose in the bolus administration group. Two observational studies, not pooled because they did not meet the a priori criteria for meta-analysis, showed that [beta]-lactam administration by extended or continuous infusion was associated with an improvement in clinical cure. The difference in the results between the meta-analysis results and the observational studies could be explained by the bias created by a higher dose of antibiotic in the bolus group in the RCTs and because many of the RCTs only recruited patients with a low acuity of illness.

The limited data available suggest that continuous infusion of [beta]-lactam antibiotics leads to the same clinical results as higher dosed bolus administration in hospitalized patients.

Benjamin M. P. Tang, Jonathan C. Craig, Guy D. Eslick, et al.

Crit Care Med, May 2009; 37(5): 1594-1603

Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS.

Randomized controlled trials (RCTs) and observational studies reported in any language that used 0.5-2.5 mg/kg/d of methylprednisolone or equivalent to treat ALI/ARDS were included.

Data were extracted independently by two reviewers and included study design, patient characteristics, interventions, and mortality and morbidity outcomes.

Both cohort studies (five studies, n = 307) and RCTs (four trials, n = 341) showed a similar trend toward mortality reduction (RCTs relative risk 0.51, 95% CI 0.24-1.09; p = 0.08; cohort studies relative risk 0.66, 95% CI 0.43-1.02; p = 0.06). The overall relative risk was 0.62 (95% CI 0.43-0.91; p = 0.01). There was also improvement in length of ventilation-free days, length of intensive care unit stay, Multiple Organ Dysfunction Syndrome Score, Lung Injury Scores, and improvement in Pao2/Fio2. There was no increase in infection, neuromyopathy, or any major complications. There was significant heterogeneity in the pooled studies. Subgroup and meta-regression analyses showed that heterogeneity had minimal effect on treatment efficacy; however, these findings were limited by the small number of studies used in the analyses.

The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.

Giuseppe Bello, Mariano Alberto Pennisi, Luca Montini, et al.

Chest, June 2009; 135(6):1448-1454

The effect of the nonthyroidal illness syndrome (NTIS) on the duration of mechanical ventilation (MV) has not been extensively investigated. This study aims to determine whether the NTIS is associated with the duration of MV in patients admitted to the ICU.

We evaluated all patients admitted over a 6-year period to our ICU who underwent invasive MV and had measurement of serum free triiodothyronine (fT3), free thyroxine (fT4), and thyroid-stimulating hormone (TSH) performed in the first 4 days after ICU admission and, subsequently, at least every 8 days during the time they received MV. The primary outcome measure was prolonged MV (PMV), which was defined as dependence on MV for > 13 days.

Two hundred sixty-four patients were included. Fifty-six patients (normal-hormone group) had normal thyroid function test results, whereas 208 patients (low-fT3 group) had, at least in one hormone dosage, low levels of fT3 with normal (n = 145)/low (n = 63) levels of fT4 and normal (n = 189)/low (n = 19) levels of TSH. Patients in the low-fT3 group showed significantly higher mortality and simplified acute physiology score II, and significantly longer duration of MV and ICU length of stay compared with the normal-hormone group. Two of the variables studied were associated with PMV, as follows: the NTIS (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.18 to 4.29; p = 0.01); and the presence of pneumonia (OR, 1.17; 95% CI, 1.06 to 3.01; p = 0.03).

The NTIS represents a risk factor for PMV in mechanically ventilated, critically ill patients.

Brain tissue oxygen and outcome after severe

traumatic brain injury: A systematic review

Eileen Maloney-Wilensky, Vicente Gracias, Arthur Itkin, et al.

Crit Care Med, June 2009; 37(6): 2057-2063In this study, available medical literature were reviewed to determine whether brain hypoxia as measured by brain tissue oxygen (Bto2) levels is associated with


duodenal versus gastric feeding in medical intensive

care unit patients: A prospective, randomized,

clinical study

Influence of surgical treatment timing on mortality

from necrotizing soft tissue infections requiring intensive

care management

Acute kidney injury in septic shock: clinical outcomes and impact of duration of

hypotension prior to initiation of antimicrobial therapy

The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus

aureus, vancomycin-resistant enterococcus, and healthcare-

associated bloodstream infections: results of a quasi-experimental multicenter trial

effects of hydroxyethyl starch resuscitation on extravascular

lung water and pulmonary permeability in sepsis-related

acute respiratory distress syndrome

Chien-Wei Hsu, Shu-Fen Sun, Shoa-Lin Lin, et al.

Crit Care Med, June 2009; 37(6): 1866-1872

To determine whether medical intensive care unit (ICU) patients receiving nasoduodenal (ND) feedings achieve optimal nutritional support and better clinical outcomes compared with patients receiving nasogastric (NG) feedings.

A prospective, randomized, clinical study. Medical ICU of a university-affiliated tertiary medical center.

One hundred twenty-one medical ICU patients required enteral feeding. Patients were randomized to receive enteral feeding. One group received ND feedings and the other group received NG feedings. All patients followed the same protocol.

The primary outcome of optimal nutritional support was assessed by measurement of time to goal tube feed rate and daily calorie and protein intake. Secondary clinical outcomes included number of ICU, hospital and ventilator days, number of the days in the study, blood-glucose levels, incidence of vomiting, diarrhea, gastrointestinal bleeding, tube replaced, tube clogged, fever, bacteremia, and ventilator-associated pneumonia (VAP), and mortality rate. Results showed that the ND group had a higher average daily calorie and protein intake compared with NG group and achieved nutritional goals earlier. In terms of clinical outcomes, patients in the ND group had a lower rate of vomiting and VAP. The other clinical outcomes such as number of ICU days, hospital days, ventilator days, blood-glucose level, tube replaced or clogged, diarrhea, gastrointestinal bleeding, fever, bacteremia, and mortality rate were not significantly different between two groups.

Patients who received ND feedings achieved nutritional goals earlier than those who received NG feeding. ND feeding group also has a lower rate of vomiting and VAP in the medical ICU setting.

Alexandre Boyer, Frederic Vargas, Fanny Coste, et al.

Intensive Care Med, June 2009; 35(5):847-853

Surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTIs). The aim of this study was to determine the influence of surgical procedure timing on hospital mortality in severe NSTI.

A retrospective study including 106 patients was conducted in a medical intensive care unit equipped with a hyperbaric chamber. Data regarding pre-existing conditions, intensive care and surgical management were included in a logistic regression model to determine independent factors associated with hospital mortality.

Overall hospital mortality was 40.6%. In multivariate analysis, underlying cardiovascular disease, SAPS II, abdominoperineal compared to limb localization, time from the first signs to diagnosis <72 h, and time from diagnosis to surgical treatment >14 h in patients with septic shock were independently associated with hospital mortality.

In patients with NSTI and septic shock, hospital mortality is influenced by the timing of surgical treatment.

Sean M. Bagshaw, Stephen Lapinsky, Sandra Dial, et al.

Intensive Care Med, June 2009; 35(5):871-881

To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI.

Retrospective cohort study a total of 4,532 adult patients with septic shock from 1989 to 2005.

Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia.

In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0–13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3–15.3) h for AKI vs. 4.3 (1.5–10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10–1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60–1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5–1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56).

Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.

Michael W. Climo, Kent A. Sepkowitz, Gianna Zuccotti, et al.


Spread of multidrug-resistant organisms within the intensive care unit (ICU) results in substantial morbidity and mortality. Novel strategies are needed to reduce transmission. This study sought to determine if the use of daily chlorhexidine bathing would decrease the incidence of colonization and bloodstream infections (BSI) because of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) among ICU patients.

Design, Setting, and Patients: Six ICUs at four academic centers measured the incidence of MRSA and VRE colonization and BSI during a period of bathing with routine soap for 6 months and then compared results with a 6-month period where all admitted patients received daily bathing with a chlorhexidine solution. Changes in incidence were evaluated by Poisson and segmented regression modeling.

Acquisition of MRSA decreased 32% (5.04 vs. 3.44 cases/1000 patient days, p = 0.046) and acquisition of VREdecreased 50% (4.35 vs. 2.19 cases/1000 patient days, p = 0.008) following the introduction of daily chlorhexidine bathing. Segmented regression analysis demonstrated significant reductions in VRE bacteremia (p = 0.02) following the introduction of chlorhexidine bathing. VRE-colonized patients bathed with chlorhexidine had a lower risk of developing VRE bacteremia (relative risk 3.35; 95% confidence interval 1.13-9.87; p = 0.035), suggesting that reductions in the level of colonization led to the observed reductions in BSI.

Chung-Chi Huang, Kuo-Chin Kao, Kuang-Hung Hsu, et al.


Hydroxyethyl starch (HES) has greater volume expansion effect and longer intravascular persistence than crystalloids. HES also decreases microvascular permeability and capillary leakage by biophysically plugging endothelial leaks, exerting an anti-inflammatory effect, and decreasing activation of endothelial cells. The aim of our study was to determine whether medium molecular weight HES (pentastarch) resuscitation in the early stage of acute respiratory distress syndrome (ARDS) simultaneously increases cardiac output without worsening pulmonary edema and whether it attenuates pulmonary vascular permeability.

Prospective observational study twenty-bed medical intensive care unit of a tertiary medical center twenty patients with early-stage ARDS

Volume expansion with a 500-mL infusion of 10% pentastarch (HES 200/0.5) at a rate of 10 mL/kg/hr.

Baseline hemodynamics including systemic and pulmonary artery blood pressures, central venous pressure, pulmonary artery occlusion pressure, and cardiac output were obtained from an online HP Component Monitoring System and a pulmonary artery catheter. Intrathoracic blood volume (ITBV), global end-diastolic volume, extravascular lung water (EVLW), and pulmonary vascular permeability (EVLW/ITBV) were measured with a PiCCOplus monitor. Hemodynamic measurements were repeated immediately and 2, 4, and 6 hours after volume expansion. Pentastarch loading significantly increased central venous pressure, pulmonary artery occlusion pressure, pulmonary arterial pressures, and cardiac output. Pulmonary mechanics, venous admixtures, and EVLW values remained unchanged throughout the study. EVLW/ITBV significantly decreased immediately after the pentastarch infusion.

In patients with early ARDS, pentastarch resuscitation significantly improved their hemodynamics and cardiac output without worsening pulmonary edema and pulmonary mechanics. It even attenuated pulmonary vascular permeability.

We conclude that daily chlorhexidine bathing among ICU patients may reduce the acquisition of MRSA and VRE. The approach is simple to implement and inexpensive and may be an important adjunctive intervention to barrier precautions to reduce acquisition of VRE and MRSA and the subsequent development of healthcare-associated BSI.

increased risk of poor outcome after traumatic brain injury (TBI). A secondary objective was to examine the safety profile of a direct BtO2 probe.

Clinical studies published between 1993 and 2008 were identified from electronic databases, Index Medicus, bibliographies of pertinent articles, and expert consultation. The following inclusion criteria were applied for outcome analysis: 1) more than 10 patients described, 2) use of a direct Bto2 monitor, 3) brain hypoxia defined as Bto2 <10 mm Hg for >15 or 30 minutes, 4) 6-month outcome data, and 5) clear reporting of patient outcome associated with Bto2. For the analysis, each selected article had to have adequate data to determine odds ratios (ORs) and confidence intervals (CIs). Thirteen studies met the initial inclusion criteria and three were included in the final outcome analysis. Safety data were abstracted from any report where it was mentioned.

The three studies included 150 evaluable patients with severe TBI (Glasgow Coma Scale <=8). Brain hypoxia was identified in 71 (47%) of these patients. Among the patients with brain hypoxia, 52 (73%) had unfavorable outcome including 39 (55%) who died. In the absence of brain hypoxia, 34 (43%) patients had an unfavorable outcome, including 17 (22%) who died. Overall brain hypoxia (Bto2 <10 mm Hg >15 minutes) was associated with worse outcome (OR 4.0; 95% CI 1.9-8.2) and increased mortality (OR 4.6; 95% CI 2.2-9.6). We reviewed published safety data; in 292 patients monitored with a Bto2 probe, only two adverse events were reported.

Summary results indicate that brain hypoxia (<10 mm Hg) is associated with worse outcome after severe TBI and that Bto2 probes are safe. These results imply that treating patients to increase Bto2 may improve outcome after severe TBI. This question will require further study.


Indraprastha Apollo Hospitals, Room No. 4162, 1st Floor, Gate No. 10, New Delhi - 110076 Telefax : 011-26825586 • Emails : [email protected]

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