Effect of high versus standard protein provision on functional recovery in people with critical illness (PRECISe): an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in Belgium and the Netherlands.

BACKGROUND: Increased protein provision might ameliorate muscle wasting and improve long-term outcomes in critically ill patients. The aim of the PRECISe trial was to assess whether higher enteral protein provision (ie, 2·0 g/kg per day) would improve health-related quality of life and functional outcomes in critically ill patients who were mechanically ventilated compared with standard enteral protein provision (ie, 1·3 g/kg per day). METHODS: The PRECISe trial was an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in five Dutch hospitals and five Belgian hospitals. Inclusion criteria were initiation of invasive mechanical ventilation within 24 h of intensive care unit (ICU) admission and an expected duration of invasive ventilation of 3 days or longer. Exclusion criteria were contraindications for enteral nutrition, moribund condition, BMI less than 18 kg/m2, kidney failure with a no dialysis code, or hepatic encephalopathy. Patients were randomly assigned to one of four randomisation labels, corresponding with two study groups (ie, standard or high protein; two labels per group) in a 1:1:1:1 ratio through an interactive web-response system. Randomisation was done via random permuted-block randomisation in varying block sizes of eight and 12, stratified by centre. Participants, care providers, investigators, outcome assessors, data analysts, and the independent data safety monitoring board were all blinded to group allocation. Patients received isocaloric enteral feeds that contained 1·3 kcal/mL and 0·06 g of protein/mL (ie, standard protein) or 1·3 kcal/mL and 0·10 g of protein/mL (ie, high protein). The study-nutrition intervention was limited to the time period during the patient's ICU stay in which they required enteral feeding, with a maximum of 90 days. The primary outcome was EuroQoL 5-Dimension 5-level (EQ-5D-5L) health utility score at 30 days, 90 days, and 180 days after randomisation, adjusted for baseline EQ-5D-5L health utility score. This trial was registered with ClinicalTrials.gov (NCT04633421) and is closed to new participants. FINDINGS: Between Nov 19, 2020, and April 14, 2023, 935 patients were randomly assigned. 335 (35·8%) of 935 patients were female and 600 (64·2%) were male. 465 (49·7%) of 935 were assigned to the standard protein group and 470 (50·3%) were assigned to the high protein group. 430 (92·5%) of 465 patients in the standard protein group and 419 (89·1%) of 470 patients in the high protein group were assessed for the primary outcome. The primary outcome, EQ-5D-5L health utility score during 180 days after randomisation (assessed at 30 days, 90 days, and 180 days), was lower in patients allocated to the high protein group than in those allocated to the standard protein group, with a mean difference of -0·05 (95% CI -0·10 to -0·01; p=0·031). Regarding safety outcomes, the probability of mortality during the entire follow-up was 0·38 (SE 0·02) in the standard protein group and 0·42 (0·02) in the high protein group (hazard ratio 1·14, 95% CI 0·92 to 1·40; p=0·22). There was a higher incidence of symptoms of gastrointestinal intolerance in patients in the high protein group (odds ratio 1·76, 95% CI 1·06 to 2·92; p=0·030). Incidence of other adverse events did not differ between groups. INTERPRETATION: High enteral protein provision compared with standard enteral protein provision resulted in worse health-related quality of life in critically ill patients and did not improve functional outcomes during 180 days after ICU admission. FUNDING: Netherlands Organisation for Healthcare Research and Development and Belgian Health Care Knowledge Centre.

Alterations in Regional Brain Microcirculation in Patients with Sepsis: A Prospective Study Using Contrast-Enhanced Brain Ultrasound.

BACKGROUND: Alterations in regional brain microcirculation have not been well studied in patients with sepsis. Regional brain microcirculation can be studied using contrast-enhanced brain ultrasound (CEUS) with microbubble administration. METHODS: CEUS was used to assess alterations in regional brain microcirculation on 3 consecutive days in 58 patients with sepsis and within 24 h of intensive care unit admission in 10 aged-matched nonseptic postoperative patients. Time-intensity perfusion curve variables (time-to-peak and peak intensity) were measured in different regions of interest of the brain parenchyma. The mean arterial pressure, cardiac index (using transthoracic echocardiography), global cerebral blood flow (using echo-color Doppler of the carotid and vertebral arteries), mean flow velocities of the middle cerebral arteries, and brain autoregulation (using transcranial echo-color Doppler) were measured simultaneously. The presence of structural brain injury in patients with sepsis was confirmed on computed tomography imaging, and encephalopathy, including coma and delirium, was evaluated using the Glasgow Coma Scale and the Confusion Assessment Method in the Intensive Care Unit. RESULTS: Of the 58 patients with sepsis, 42 (72%) developed acute encephalopathy and 11 (19%) had some form of structural brain injury. Brain autoregulation was impaired in 23 (40%) of the patients with sepsis. Brain microcirculation alterations were observed in the left lentiform nucleus and left white matter of the temporoparietal region of the middle cerebral artery in the sepsis nonsurvivors but not in the survivors or postoperative patients. The alterations were characterized by prolonged time-to-peak (p < 0.01) and decreased peak intensity (p < 0.01) on the time-intensity perfusion curve. Prolonged time-to-peak but not decreased peak intensity was independently associated with worse outcome (p = 0.03) but not with the development of encephalopathy (p = 0.77). CONCLUSIONS: Alterations in regional brain microcirculation are present in critically ill patients with sepsis and are associated with poor outcome. Trial registration Registered retrospectively on December 19, 2019.

Indirect Calorimetry in Spontaneously Breathing, Mechanically Ventilated and Extracorporeally Oxygenated Patients: An Engineering Review.

Indirect calorimetry (IC) is considered the gold standard for measuring resting energy expenditure (REE). This review presents an overview of the different techniques to assess REE with special regard to the use of IC in critically ill patients on extracorporeal membrane oxygenation (ECMO), as well as to the sensors used in commercially available indirect calorimeters. The theoretical and technical aspects of IC in spontaneously breathing subjects and critically ill patients on mechanical ventilation and/or ECMO are covered and a critical review and comparison of the different techniques and sensors is provided. This review also aims to accurately present the physical quantities and mathematical concepts regarding IC to reduce errors and promote consistency in further research. By studying IC on ECMO from an engineering point of view rather than a medical point of view, new problem definitions come into play to further advance these techniques.

Effect of extracorporeal carbon dioxide removal on respiratory quotient measured by indirect calorimetry: Unravelling the mystery.

NEW FINDINGS: What is the main observation in this case? Several studies have reported progressive hypoxaemia once extracorporeal carbon dioxide removal is started in patients with hypercapnic respiratory failure, possibly attributable to an altered respiratory quotient. What insights does it reveal? In this quality control report, we show that the respiratory quotient exhibits only minimal alteration when extracorporeal carbon dioxide removal is started and assume that the progressive hypoxaemia is attributable to an increase in intrapulmonary shunt. ABSTRACT: The use of extracorporeal carbon dioxide removal (ECCO2 R) has been proposed in patients with acute respiratory distress syndrome to achieve lung-protective ventilation and in patients with selective hypercapnic respiratory failure. However, several studies have reported progressive hypoxaemia, as expressed by a need to increase the inspired oxygen fraction (Fi O2 ) to maintain adequate oxygenation or by a decrease in the ratio of arterial oxygen tension (Pa O2 ) to Fi O2 once ECCO2 R is started. We present the case of a patient who was admitted to the intensive care unit for a coronavirus disease 2019 pneumonia and who was intubated because of hypercapnic respiratory insufficiency. Extracorporeal carbon dioxide removal was started, and the patient subsequently developed progressive hypoxaemia. To test whether the hypoxaemia was attributable to the ECCO2 R, blood samples were taken in different settings: (1) 'no ECCO2 R', blood flow 150 ml/min with a ECCO2 R gas flow of 0 L/min; and (2) 'with ECCO2 R', blood flow 400 ml/min with gas flow 12 L/min. We measured Pa O2 , alveolar oxygen tension, Pa O2 /Fi O2 , alveolar-arterial oxygen tension difference, arterial carbon dioxide tension and the respiratory quotient (RQ) by indirect calorimetry in each setting. The RQ was 0.60 without ECCO2 R and 0.57 with ECCO2 R. The alveolar oxygen tension was 220.4 mmHg without ECCO2 R and increased to 240.3 mmHg with ECCO2 R, whereas Pa O2 /Fi O2 decreased from 177 to 171. Our study showed only a minimal change in RQ when ECCO2 R was started. We were the first to measure the RQ directly, before and after the initiation of ECCO2 R, in a patient with hypercapnic respiratory failure.

Indirect calorimetry in critical illness: a new standard of care?

PURPOSE OF REVIEW: Review recent literature on the role of indirect calorimetry in critical care nutrition management. RECENT FINDINGS: Critical illness demands objective, targeted nutritional therapy to prevent adverse effects of underfeeding/over feeding. Thus, all recent societal guidelines recommend indirect calorimetry use to determine energy needs. Very recently, indirect calorimetry technology has finally evolved to allow for accurate, simple, and routine utilization in a wider range of ICU patients. Recent data continues to confirm poor correlation between measured and equation-predicted energy expenditure emphasizing need for indirect calorimetry to be standard of care. This may be particularly true in COVID-19, where significant progressive hypermetabolism and variability in energy expenditure has been shown. Metabolic physiology can change frequently during ICU stay in response to changes in clinical condition or care. Thus, repeated longitudinal indirect calorimetry measures are needed throughout ICU stay to optimize care, with initial data showing improved clinical outcomes when indirect calorimetry targets are utilized. SUMMARY: Personalized ICU care demands objective data to guide therapy. This includes use of indirect calorimetry to determine energy expenditure and guide ICU nutrition therapy. Long-awaited new innovations in indirect calorimetry technology should finally lead to indirect calorimetry to becoming a fundamental component of modern ICU standard of care and clinical research moving forward.

An endotracheal tube providing "pressurized sealing" prevents fluid leakage in mechanically ventilated critically ill patients: a pilot study.

Microaspiration of bacteriologically contaminated oropharyngeal secretions alongside the cuff of an endotracheal tube (ETT) is a key mechanism for development of ventilator-associated pneumonia. We have constructed a prototype double-cuffed ETT equipped with a supplemental port in-between the cuffs through which continuous positive airway pressure (CPAP) is delivered. Pressure in the intercuff space propels secretions upwards and produces 100% tracheal sealing in an in vitro model. We conducted a 24 h study to investigate the sealing effect of this ETT in 12 critically ill mechanically ventilated patients. Methylene blue, instilled through a bronchoscope on top of the proximal cuff, was used as leakage tracer. Fiberoptic visualisation of the trachea was performed 1 h and 24 h thereafter. Leakage was confirmed if blue dye was detected on the tracheal mucosa beyond the tip of the ETT. In no patient, dye passed by the cuffs during the study period. Presence of the ETT did not interfere with ventilator settings, patient mobilization, physiotherapy, and technical acts. Overall, pressures in the intercuff space remained between 10 and 15 cmH2O. Excessive pressure swings were swiftly corrected by the CPAP system. A double-cuffed ETT, offering "pressurized sealing" of the trachea, safely and effectively prevented leakage during 24 h mechanical ventilation.

Energy expenditure of patients on ECMO: A prospective pilot study.

BACKGROUND: An optimal nutritional approach sustained by convenient monitoring of metabolic status and reliable assessment of energy expenditure (EE) may improve the outcome of critically ill patients on extracorporeal membrane oxygenation (ECMO). We previously demonstrated the feasibility of indirect calorimetry (IC)-the standard of care technique to determine caloric targets-in patients undergoing ECMO. This study aims to compare measured with calculated EE during ECMO treatment. We additionally provide median EE values for use in settings where IC is not available. METHODS: IC was performed in seven stable ECMO patients. Gas exchange was analyzed at the ventilator, and ECMO side and values were introduced in a modified Weir formula to calculate resting EE. Results were compared with EE calculated with the Harris-Benedict equation and with the 25 kcal/kg/day ESPEN recommendation. RESULTS: Total median oxygen consumption rate was 196 (Q1-Q3 158-331) mL/min, and total median carbon dioxide production was 150 (Q1-Q3 104-203) mL/min. Clinically relevant differences between calculated and measured EE were observed in all patients. The median EE was 1334 (Q1-Q3 1134-2119) kcal/24 hours or 18 (Q1-Q3 15-27) kcal/kg/day. CONCLUSION: Compared with measured EE, calculation of EE both over- and underestimated caloric needs during ECMO treatment. Despite a median EE of 21 kcal/kg/day, large variability in metabolic rate was found and demands further investigation.

CO2 and O2 removal during continuous veno-venous hemofiltration: a pilot study.

BACKGROUND: Carbon dioxide (CO2) accumulation is a challenging issue in critically ill patients. CO2 can be eliminated by renal replacement therapy but studies are scarce and clinical relevance is unknown. We prospectively studied CO2 and O2 behavior at different sample points of continuous veno-venous hemofiltration (CVVH) and build a model to calculate CO2 removal bedside. METHODS: In 10 patients receiving standard CVVH under citrate anticoagulation, blood gas analysis was performed at different sample points within the CVVH circuit. Citrate was then replaced by NaCl 0.9% and sampling was repeated. Total CO2 (tCO2), CO2 flow (V̇CO2) and O2 flow (V̇O2) were compared between different sample points. The effect of citrate on transmembrane tCO2 was evaluated. Wilcoxon matched-pairs signed rank test was performed to evaluate significance of difference between 2 data sets. Friedman test was used when more data sets were compared. RESULTS: V̇CO2 in the effluent (26.0 ml/min) correlated significantly with transmembrane V̇CO2 (24.2 ml/min). This represents 14% of the average expired V̇CO2 in ventilated patients. Only 1.3 ml/min CO2 was removed in the de-aeration chamber, suggesting that CO2 was almost entirely cleared across the membrane filter. tCO2 values in effluent, before, and after the filter were not statistically different. Transmembrane tCO2 under citrate or NaCl 0.9% predilution also did not differ significantly. No changes in V̇O2 were observed throughout the CVVH circuit. Based on recorded data, formulas were constructed that allow bedside evaluation of CVVH-attributable CO2 removal. CONCLUSION: A relevant amount of CO2 is removed by CVVH and can be quantified by one simple blood gas analysis within the circuit. Future studies should assess the clinical impact of this observation. TRIAL REGISTRATION: The trial was registered at https://clinicaltrials.gov with trial registration number NCT03314363 on October 192,017.

Correction to: CO2 and O2 removal during continuous veno-venous hemofiltration: a pilot study.

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The impact of the COVID-19 pandemic on gram-negative bacteria susceptibility patterns in respiratory samples of intensive care units in the Brussels Capital Region, 2010-2021.

BACKGROUND: The effect of the Coronavirus Disease 2019 (COVID-19) pandemic on gram-negative bacteria nonsusceptibility to antibiotics is unclear. METHODS: Between January 1, 2010, and December 31, 2021, the respiratory samples of intensive care unit patients at 3 University Hospitals in Brussels were retrieved. Based on the nonsusceptibility to antimicrobial classes, drug-resistance patterns were defined as multi-drug-resistant, extensively drug-resistant, and pan-drug-resistant. The study time frame was divided into 6 periods of 2 years each, and the impact of the COVID-19 pandemic (last period: 2020-2021) was assessed. RESULTS: During the current study, 10,577 samples were identified from 5,889 patients. While a significant augmentation of multi-drug-resistant isolates was noticed once comparing 2 prepandemic periods (2012-2013 and 2014-2015), all 3 patterns of nonsusceptibility significantly increased, comparing the years before and throughout the COVID-19 pandemic (2018-2019 and 2020-2021). Globally, the greatest increase in antimicrobial nonsusceptibility, comparing the last 2 periods, was reported for piperacillin-tazobactam (from 28% to 38%). Pseudomonas aeruginosa was the most isolated species, and the most involved in the appearance of resistance, with an augmentation of nonsusceptibility percentage to meropenem of 22% (from 25% to 47%), between the prepandemic and the pandemic periods. CONCLUSIONS: The COVID-19 pandemic was associated with increasing trends of antimicrobial resistance in respiratory samples of patients admitted to the intensive care units in university hospitals with well-implemented antibiotic stewardship programs.

Five-year VIM-producing Pseudomonas aeruginosa outbreak in four Belgian ICUs, an investigation report (2019-2023).

BACKGROUND: Verona integron-encoded metallo-ß-lactamase-producing Pseudomonas aeruginosa (VIM-PA) outbreaks are frequently linked to contaminated sink-drains in the intensive care unit (ICU). This study aims to investigate a VIM-PA outbreak occurring at 4 ICUs in a Belgian university center. METHODS: Between 01/01/2019 and 30/07/2023, data were retrospectively retrieved. Whole-genome sequencing of VIM-PA was carried out for available isolates and the core genome multilocus sequencing typing (cgMLST) was used to confirm clonality. New case incidence was estimated by analyzing the weekly data of at-risk and VIM-PA-colonized patients, fitting a regression model. RESULTS: Fifty-one patients were colonized, among them, 32 (63%) were infected by VIM-PA, which contributed to 7 deaths. The outbreak investigation showed that 19 (47%) of the examined sink-drains grew at least once a VIM-PA. Two major clusters were observed by cgMLST: ST111 (59 clones with 40 clinical isolates), and ST17 (8 clones with 6 clinical isolates). The estimated incidence rate of new cases was significantly higher in one unit. CONCLUSIONS: A 5-year prolonged outbreak at the UZ Brussel ICUs was caused by only 2 VIM-PA clones, both linked to sink-drains, with minimal mutations occurring throughout the years. Statistical modeling found different incidence rates between units. Tailored interventions were hence prioritized.

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease.

BACKGROUND AND AIMS: Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD. METHODS: The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process. RESULTS: The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements. CONCLUSION: The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

Effective Treatment of Acute Tricyclic Antidepressant Poisoning with Cardiogenic Shock and Severe Rhabdomyolysis Using ECMO and CytoSorb® Adsorber.

BACKGROUND Tricyclic antidepressant (TCA) drugs are a common cause of fatal poisoning because of their cardiotoxic and arrhythmogenic effects. Classic supportive management includes sodium bicarbonate, gastrointestinal chelating agents, and vasopressors. Recently, intravenous lipid emulsion (supported by a low evidence level) has also been used. CASE REPORT We report the case of a 55-year-old woman admitted to our Intensive Care Unit (ICU) with acute imipramine self-poisoning. She arrived at the emergency department 7 hours after imipramine ingestion; she had severe rhabdomyolysis upon admission, with creatine phosphokinase levels at about 52 500 IU/L (normal, <200 IU/L). She quickly developed cardiogenic shock and malign arrhythmia requiring veno-arterial extra corporeal membrane oxygenation (VA-ECMO). Continuous renal replacement therapy (CRRT) with CytoSorb® (CytoSorbents, Monmouth Junction, New York, United Sates of America) was started 19 hours after admission. We performed serial blood measurements of imipramine and its active metabolite desipramine as well as viewing the levels on the CRRT-circuit monitor. Cardiac function improved and ECMO was explanted after 4 days. She also had severe acute respiratory distress syndrome, which resolved spontaneously. The neurologic outcome was favorable despite early myoclonus. The patient regained consciousness on the fifth day. Her clinical evolution was marked by acute ischemia of the lower left limb due to the arterial ECMO cannula. CONCLUSIONS These measurements document the efficacy of the CytoSorb® adsorber in removing a lipophilic drug from a patient's bloodstream. To our knowledge, this is the first published case of CytoSorb® extracorporeal blood purification therapy for acute TCA poisoning.

Parenteral Nutrition, Sepsis, Acute Heart Failure and Hepatotoxic Drugs Are Related to Liver Test Disturbances in Critically Ill Patients.

BACKGROUND: Parenteral nutrition (PN) is often associated with liver dysfunction in the ICU, although other factors such as sepsis, acute heart failure (AHF), and hepatotoxic drugs can be equally present. The relative impact of PN on liver dysfunction in critically ill patients is largely unknown. METHODS: We recorded the presence of pre-existing liver disturbances, AHF, sepsis, daily PN volume, and commonly used hepatotoxic drugs in adult ICU patients, together with daily aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), alkalic phosphatase (AP), total bilirubin (TB), and INR values in patients with three or more PN treatment days. A linear mixed-effects model was used to assess the relative contribution of each liver parameter. Nutritional adequacy was defined as intake/needs. RESULTS: We included 224 ICU patients with PN treatment lasting more than 3 days between 1 January 2017 and 31 December 2019. For AST, pre-existing liver disturbances (+180% ± 11%) and the presence of AHF (+75% ± 14%) were the main predictors of deterioration, whereas PN volume caused only a limited increase of 14% ± 1%/L. Similar results were observed for ALT. GGT, INR, and TB are mainly influenced by the presence of sepsis/septic shock and pre-existing liver disturbances, with no impact of PN or hepatotoxic drugs. Carbohydrate intake exceeded recommendations, and protein and lipid intake were insufficient in this study cohort. CONCLUSIONS: Liver test disturbances in ICU patients on PN are multifactorial, with sepsis and AHF having the highest influence, with only limited impact from PN and hepatotoxic drugs. Feeding adequacy can be improved.

Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice.

Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.

Cirrhosis and partial portal thrombosis leading to severe variceal bleeding, an unusual presentation of sarcoidosis.

INTRODUCTION: Sarcoidosis is a systemic granulomatous disease, characterized by the formation of non-necrotizing granulomas. Even though granulomas are frequently found in liver biopsy, related symptoms rarely occur. In the current article, a case report is pictured to increase the knowledge on portal hypertension in hepatic sarcoidosis. CLINICAL SITUATION: A 62-year-old female was diagnosed with variceal bleeding for which elastic banding was performed. The patient was admitted to the intensive care unit (ICU) as the bleeding persisted and she evolved in hemorrhagic shock. Liver ultrasound detected nodular hepatomegaly and partial portal thrombosis. Chest CT showed diffuse hilar adenopathies and interstitial micronodular lesion. Finally, PET-CT detected metabolic active liver, bone marrow, and upper and lower diaphragmatic adenopathies. CLINICAL RESOLUTION: Multidisciplinary discussion brought major advantages in rapid diagnosis and prompt effective treatment. Cirrhosis was diagnosed by liver nodularity on imaging and liver biopsy. Sarcoidosis diagnosis was supported by the biopsies of liver and lymph node, which yielded non-caseating granulomas infiltration. Chest CT scan and PET-CT were also consistent with this diagnosis. The complementary analysis excluded differential diagnosis. The patient was treated with high-dose methylprednisolone with notable clinical improvements and discharge from the ICU. CONCLUSION: Hepatic sarcoidosis can present as life-threatening bleeding due to variceal bleeding caused by portal hypertension. Differential diagnosis is broad when hepatic sarcoidosis is suspected. Therefore, a multidisciplinary discussion is warranted. Anatomopathological examination of two potentially involved organs should be considered to make the appropriate diagnosis. Further studies are requested to investigate the pathophysiological mechanism of portal hypertension.

Bioenergetic Balance of Continuous Venovenous Hemofiltration, a Retrospective Analysis.

(1) Background: Nutrition therapy guided by indirect calorimetry (IC) is the gold standard and is associated with lower morbidity and mortality in critically ill patients. When performing IC during continuous venovenous hemofiltration (CVVH), the measured VCO2 should be corrected for the exchanged CO2 to calculate the 'true' Resting Energy Expenditure (REE). After the determination of the true REE, the caloric prescription should be adapted to the removal and addition of non-intentional calories due to citrate, glucose, and lactate in dialysis fluids to avoid over- and underfeeding. We aimed to evaluate this bioenergetic balance during CVVH and how nutrition therapy should be adapted. (2) Methods: This post hoc analysis evaluated citrate, glucose, and lactate exchange. Bioenergetic balances were calculated based on these values during three different CVVH settings: low dose with citrate, high dose with citrate, and low dose without citrate. The caloric load of these non-intentional calories during a CVVH-run was compared to the true REE. (3) Results: We included 19 CVVH-runs. The bioenergetic balance during the low dose with citrate was 498 ± 110 kcal/day (range 339 to 681 kcal/day) or 26 ± 9% (range 14 to 42%) of the true REE. During the high dose with citrate, it was 262 ± 222 kcal/day (range 56 to 262 kcal/day) or 17 ± 11% (range 7 to 32%) of the true REE. During the low dose without citrate, the bioenergetic balance was -189 ± 77 kcal/day (range -298 to -92 kcal/day) or -13 ± 8% (range -28 to -5%) of the true REE. (4) Conclusions: Different CVVH settings resulted in different bioenergetic balances ranging from -28% up to +42% of the true REE depending on the CVVH fluids chosen. When formulating a caloric prescription during CVVH, an individual approach considering the impact of these non-intentional calories is warranted.

Methodological Aspects of Indirect Calorimetry in Patients with Sepsis-Possibilities and Limitations.

The aim of the review was to analyse the challenges of using indirect calorimetry in patients with sepsis, including the limitations of this method. A systematic review of the literature was carried out. The analysis concerned the methodology and presentation of research results. In most studies assessing energy expenditure, energy expenditure was expressed in kcal per day (n = 9) and as the mean and standard deviation (n = 7). Most authors provided a detailed measurement protocol, including measurement duration (n = 10) and device calibration information (n = 7). Ten papers provided information on the day of hospitalisation when the measurements were obtained, nine on patient nutrition, and twelve on the criteria for inclusion and exclusion of participants from the study. Small study group sizes and study at a single centre were among the most cited limitations. Studies assessing energy expenditure in patients with sepsis by indirect calorimetry differ in the methodology and presentation of results, and their collective analysis is difficult. A meta-analysis of the results could enable multi-site and large patient evaluation. Standardisation of protocols and presentation of all collected data would enable their meta-analysis, which would help to achieve greater knowledge about metabolism in sepsis.

Performance of NUTRIC score to predict 28-day mortality in critically ill patients after replacing APACHE II with SAPS 3.

OBJECTIVES: The Nutrition Risk in the Critically Ill (NUTRIC) score has been advocated as a screening tool for nutrition risk assessment in critically ill patients. It was developed and validated to predict 28-day mortality using Acute Physiology and Chronic Health Evaluation II (APACHE II) score as one of its components. However, nowadays the Simplified Acute Physiology Score 3 (SAPS 3) demonstrates better performance. We aimed to test the performance of NUTRIC score in predicting 28-day mortality after replacement of APACHE II by SAPS 3, and the interaction between nutrition adequacy and mortality. METHODS: Adult patients who received nutrition therapy and remained >3 days in intensive care unit were retrospectively evaluated. In order to replace APACHE II component, we used ranges of SAPS 3 with similar predicted mortality. Discrimination between these tools in predicting 28-day mortality was assessed using the ROC curve, calibration was evaluated with calibration belt, and correlation with intraclass correlation. The relationship between nutritional adequacy and mortality was assessed in a subgroup with available data. RESULTS: 542 patients were analyzed (median age of 78 years old, 73.4% admitted for non-surgical reasons and 28-day mortality was 18.1%). Mortality prediction discrimination did not differ between tools (p>0.05), but showed a good agreement (intraclass correlation 0.86) with good calibration. In the subgroup analysis for nutritional adequacy (n = 99), no association with mortality was observed. CONCLUSION: Performance of NUTRIC score with SAPS 3 is similar to the original tool. Therefore, it might be used in settings where APACHE II is not available.

Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit.

Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized X-ray device was developed. We aimed to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized X-ray device was developed to perform 15 radiographic projections while translating the X-ray tube 25 cm (10 cm ramp up and 15 cm during X-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest X-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest X-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable X-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces while avoiding intrahospital transport and limiting radiation exposure compared to CT.