-
1.
Regional citrate anticoagulation for continuous renal replacement therapy.
Kindgen-Milles, D, Brandenburger, T, Dimski, T
Current opinion in critical care. 2018;(6):450-454
Abstract
PURPOSE OF REVIEW The delivery of an effective dialysis dose in continuous renal replacement therapy (CRRT) depends on adequate anticoagulation of the extracorporeal circuit. In most patients, either systemic heparin anticoagulation (SHA) or regional citrate anticoagulation (RCA) is used. This review will outline the basics and rationale of RCA and summarize data on safety and efficacy of both techniques. RECENT FINDINGS The basic principle of RCA is to reduce the level of ionized calcium in the extracorporeal circuit via infusion of citrate. This way, effective anticoagulation restricted to the extracorporeal circuit is achieved. SHA and RCA were compared in a variety of studies. RCA significantly prolonged filter lifetime, reduced bleeding complications and provided excellent control of uremia and acid-base status. RCA was also safe in the majority of patients with impaired liver function, whereas caution must be exerted in those with severe multiorgan failure and persistent hyperlactatemia. SUMMARY RCA per se is safe and effective for anticoagulation of CRRT. Compared to SHA, efficacy of anticoagulation is improved and adverse effects are reduced. RCA can be recommended as the anticoagulation mode of choice for CRRT in most ICU patients.
-
2.
Autophagy and Its Implications Against Early Full Nutrition Support in Critical Illness.
Van Dyck, L, Casaer, MP, Gunst, J
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018;(3):339-347
Abstract
The timing, dose, and route of early nutrition support in critically ill patients have been highly controversial for years. Despite the association of a caloric deficit with adverse outcome, several recent large, randomized, controlled trials have demonstrated a prolongation of organ failure and increased muscle weakness with increasing doses of nutrition in the acute phase of critical illness. A potential explanation for the negative impact of early, full feeding on outcome is feeding-induced suppression of autophagy, a cellular repair process that is necessary to clear intracellular damage. Whether nutrition management in critically ill patients should be guided by its effects on autophagy is a topic of debate. Currently, however, autophagy cannot be monitored in clinical practice. Moreover, clinical management should be guided by high-quality randomized controlled trials, which currently do not support the use of early full nutrition support.
-
3.
Intravenous fluid therapy for hospitalized and critically ill children: rationale, available drugs and possible side effects.
Langer, T, Limuti, R, Tommasino, C, van Regenmortel, N, Duval, ELIM, Caironi, P, Malbrain, MLNG, Pesenti, A
Anaesthesiology intensive therapy. 2018;(1):49-58
Abstract
Human beings are constituted mainly of water. In particular, children's total body water might reach 75-80% of their body weight, compared to 60-70% in adults. It is therefore not surprising, that children, especially hospitalized newborns and infants, are markedly prone to water and electrolyte imbalances. Parenteral fluid therapy is a cornerstone of medical treatment and is thus of exceptional relevance in this patient population. It is crucial to appreciate the fact that intravenous fluids are drugs with very different characteristics, different indications, contraindications and relevant side effects. In the present review, we will summarize the physiology and pathophysiology of water and electrolyte balance, underlining the importance and high prevalence of non-osmotic antidiuretic hormone release in hospitalized and critically ill children. Furthermore, we will discuss the characteristics and potential side effects of available crystalloids for the paediatric population, making a clear distinction between fluids that are hypotonic or isotonic as compared to normal plasma. Finally, we will review the current clinical practice regarding the use of different parenteral fluids in children, outlining both the current consensus on fluids employed for resuscitation and replacement and the ongoing debate concerning parenteral maintenance fluids.
-
4.
Fibroblast Growth Factor 23 Associates with Death in Critically Ill Patients.
Leaf, DE, Siew, ED, Eisenga, MF, Singh, K, Mc Causland, FR, Srivastava, A, Alp Ikizler, T, Ware, LB, Ginde, AA, Kellum, JA, et al
Clinical journal of the American Society of Nephrology : CJASN. 2018;(4):531-541
-
-
Free full text
-
Abstract
BACKGROUND AND OBJECTIVES Dysregulated mineral metabolism is a common and potentially maladaptive feature of critical illness, especially in patients with AKI, but its association with death has not been comprehensively investigated. We sought to determine whether elevated plasma levels of the osteocyte-derived, vitamin D-regulating hormone, fibroblast growth factor 23 (FGF23), are prospectively associated with death in critically ill patients with AKI requiring RRT, and in a general cohort of critically ill patients with and without AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We measured plasma FGF23 and other mineral metabolite levels in two cohorts of critically ill patients (n=1527). We included 817 patients with AKI requiring RRT who enrolled in the ARF Trial Network (ATN) study, and 710 patients with and without AKI who enrolled in the Validating Acute Lung Injury biomarkers for Diagnosis (VALID) study. We hypothesized that higher FGF23 levels at enrollment are independently associated with higher 60-day mortality. RESULTS In the ATN study, patients in the highest compared with lowest quartiles of C-terminal (cFGF23) and intact FGF23 (iFGF23) had 3.84 (95% confidence interval, 2.31 to 6.41) and 2.08 (95% confidence interval, 1.03 to 4.21) fold higher odds of death, respectively, after adjustment for demographics, comorbidities, and severity of illness. In contrast, plasma/serum levels of parathyroid hormone, vitamin D metabolites, calcium, and phosphate were not associated with 60-day mortality. In the VALID study, patients in the highest compared with lowest quartiles of cFGF23 and iFGF23 had 3.52 (95% confidence interval, 1.96 to 6.33) and 1.93 (95% confidence interval, 1.12 to 3.33) fold higher adjusted odds of death. CONCLUSIONS Higher FGF23 levels are independently associated with greater mortality in critically ill patients.
-
5.
Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study.
Wesselink, E, Koekkoek, KWAC, Looijen, M, van Blokland, DA, Witkamp, RF, van Zanten, ARH
Clinical nutrition ESPEN. 2018;:78-86
Abstract
BACKGROUND Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms. METHODS This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression. RESULTS In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245). CONCLUSIONS Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.
-
6.
Emerging outcome measures for nutrition trials in the critically ill.
Bear, DE, Griffith, D, Puthucheary, ZA
Current opinion in clinical nutrition and metabolic care. 2018;(6):417-422
Abstract
PURPOSE OF REVIEW Mortality has long been the gold-standard outcome measure for intensive care clinical trials. However, as the critical care community begins to understand and accept that survivorship is associated with functional disability and a health and socioeconomic burden, the clinical and research focus has begun to shift towards long-term physical function RECENT FINDINGS To use mortality as a primary outcome measure, one would either have to choose an improbable effect (e.g. a difference of 5-10% in mortality as a result of a single intervention) or recruit a larger number of patients, the latter being unfeasible for most critical care trials.Outcome measures will need to match interventions. As an example, amino acids, or intermittent feeding, can stimulate muscle protein synthesis, and so prevention of muscle wasting may seem an appropriate outcome measure when assessing the effectiveness of these interventions. Testing the effectiveness of these interventions requires the development of novel outcome measures that are targeted and acceptable to patients. We describe advancements in dual-energy X-ray absorptiometry scanning, bio-impedence analysis, MRI and muscle ultrasound in this patient group that are beginning to address this development need. SUMMARY New approaches to outcome assessment are beginning to appear in post-ICU research, which promise to improve our understanding of nutrition and exercise interventions on skeletal muscle structure, composition and function, without causing undue suffering to the patient.
-
7.
Nutrition Support in Adult Patients Receiving Extracorporeal Membrane Oxygenation.
Bear, DE, Smith, E, Barrett, NA
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018;(6):738-746
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for both severe respiratory and cardiac failure is increasing. Because these patients are some of the sickest in the intensive care unit, a multidisciplinary approach to their treatment, including appropriate nutrition therapy, is warranted. Currently, limited data exist on the optimal timing, type, and amount of nutrition to be provided. This review focuses on describing the current nutrition practices in patients receiving ECMO, details research that is currently being undertaken, and lists important research questions that require exploration in this field. Observational data suggest that early enteral nutrition is safe and that although nutrition targets can be met, underfeeding is still common. Until further research is available, these patients should be fed according to guidelines for the general critically unwell population.
-
8.
Bedside electromagnetic-guided placement of nasoenteral feeding tubes among critically Ill patients: A single-centre randomized controlled trial.
Gao, X, Zhang, L, Zhao, J, Tian, F, Sun, H, Wang, P, Wang, J, Wang, Z, Wang, X
Journal of critical care. 2018;:216-221
Abstract
PURPOSE We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement among critically ill patients. MATERIALS AND METHODS We performed a single-center, randomized controlled trial among 161 adult patients admitted to intensive care units (ICUs) requiring nasoenteral feeding. Patients were randomly assigned to EM-guided or endoscopic nasoenteral feeding tube placement (1:1). The primary end point was the total success rate of correct jejunal placement. RESULTS This was achieved in 74/81 and 76/80 patients who underwent EM-guided and endoscopic jejunal tube placements, respectively (91.4% vs. 95%; relative risk, 0.556; [CI], 0.156-1.980; P = 0.360). The EM-guided group had more placement attempts, longer placement time, and shorter inserted nasal intestinal tube length. However, they had shorter total placement procedure duration and physician's order-tube placement and order-start of feeding intervals. The EM-guided group had higher discomfort level and recommendation scores and lesser patient costs. This trial is registered at Chinese Clinical Trials Registry (ChiCTR-IOR-17011737). CONCLUSION Bedside EM-guided placement is as fast, safe, and successful as endoscopic placement and may be considered the preferred technique in critically ill patients.
-
9.
Full Nutrition or Not?
Stuever, MF, Kidner, RF, Chae, FE, Evans, DC
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2018;(3):333-338
Abstract
Enteral nutrition (EN) is widely used in intensive care units around the world, but the optimal dosing strategy during the first week of critical illness is still controversial. Numerous studies in the past decade have provided conflicting recommendations regarding the roles of trophic and permissive/intentional underfeeding strategies. Further complicating effective medical decision making is the widespread, yet unintentional and persistent underdelivery of prescribed energy and protein, in addition to the trend for recommending ever-higher amounts of protein delivery. We postulate that the key to appropriate enteral strategy lies within an accurate and patient-specific assessment. Patients with a baseline high nutrition risk and those with increased nutrition demands, such as those with wounds, surgery, or burns, likely require full nutrition support, in contrast with medical patients, such as those with acute respiratory distress syndrome, who may selectively be appropriate for trophic strategies. In this analysis, we review several key trials for and against full EN in the first week of critical illness, as well as key issues such as the role of autophagy and immunonutrition in enteral dose selection.
-
10.
Intravenous fluid therapy in critically ill adults.
Finfer, S, Myburgh, J, Bellomo, R
Nature reviews. Nephrology. 2018;(9):541-557
Abstract
Intravenous fluid therapy is one of the most common interventions in acutely ill patients. Each day, over 20% of patients in intensive care units (ICUs) receive intravenous fluid resuscitation, and more than 30% receive fluid resuscitation during their first day in the ICU. Virtually all hospitalized patients receive intravenous fluid to maintain hydration and as diluents for drug administration. Until recently, the amount and type of fluids administered were based on a theory described over 100 years ago, much of which is inconsistent with current physiological data and emerging knowledge. Despite their widespread use, various fluids for intravenous administration have entered clinical practice without a robust evaluation of their safety and efficacy. High-quality, investigator-initiated studies have revealed that some of these fluids have unacceptable toxicity; as a result, several have been withdrawn from the market (while others, controversially, are still in use). The belief that dehydration and hypovolaemia can cause or worsen kidney and other vital organ injury has resulted in liberal approaches to fluid therapy and the view that fluid overload and tissue oedema are 'normal' during critical illness; this is quite possibly harming patients. Increasing evidence indicates that restrictive fluid strategies might improve outcomes.