COVID-19 mortality risk for older men and women.

BACKGROUND: Case-fatality from COVID-19 has been reported to be relatively high in patients age 65 years or older. We sought to determine the age-specific rates of COVID-19 mortality at the population level. METHODS: We obtained information regarding the total number of COVID-19 reported deaths for six consecutive weeks beginning at the 50th recorded death, among 16 countries that reported a relatively high number of COVID-19 cases as of April 12, 2020. We performed an ecological study to model COVID-19 mortality rates per week by age group (54 years or younger, 55-64 years, and 65 years or older) and sex using a Poisson mixed effects regression model. RESULTS: Over the six-week period of data, there were 178,568 COVID-19 deaths from a total population of approximately 2.4 billion people. Age and sex were associated with COVID-19 mortality. Compared with individuals ages 54 years or younger, the incident rate ratio (IRR) was 8.1, indicating that the mortality rate of COVID-19 was 8.1 times higher (95%CI = 7.7, 8.5) among those 55 to 64 years, and more than 62 times higher (IRR = 62.1; 95%CI = 59.7, 64.7) among those ages 65 or older. Mortality rates from COVID-19 were 77% higher in men than in women (IRR = 1.77, 95%CI = 1.74, 1.79). CONCLUSIONS: In the 16 countries examined, persons age 65 years or older had strikingly higher COVID-19 mortality rates compared to younger individuals, and men had a higher risk of COVID-19 death than women.

Haemodynamic monitoring in the intensive care unit: results from a web-based Swiss survey.

BACKGROUND: The aim of this survey was to describe, in a situation of growing availability of monitoring devices and parameters, the practices in haemodynamic monitoring at the bedside. METHODS: We conducted a Web-based survey in Swiss adult ICUs (2009-2010). The questionnaire explored the kind of monitoring used and how the fluid management was addressed. RESULTS: Our survey included 71% of Swiss ICUs. Echocardiography (95%), pulmonary artery catheter (PAC: 85%), and transpulmonary thermodilution (TPTD) (82%) were the most commonly used. TPTD and PAC were frequently both available, although TPTD was the preferred technique. Echocardiography was widely available (95%) but seems to be rarely performed by intensivists themselves. Guidelines for the management of fluid infusion were available in 45% of ICUs. For the prediction of fluid responsiveness, intensivists rely preferentially on dynamic indices or echocardiographic parameters, but static parameters, such as central venous pressure or pulmonary artery occlusion pressure, were still used. CONCLUSIONS: In most Swiss ICUs, multiple haemodynamic monitoring devices are available, although TPTD is most commonly used. Despite the usefulness of echocardiography and its large availability, it is not widely performed by Swiss intensivists themselves. Regarding fluid management, several parameters are used without a clear consensus for the optimal method.

Epoetin administrated after cardiac surgery: effects on renal function and inflammation in a randomized controlled study.

BACKGROUND: Experimentally, erythropoietin (EPO) has nephroprotective as well as immunomodulatory properties when administered after ischemic renal injury. We tested the hypothesis that different doses of recombinant human EPO administered to patients after cardiac surgery would minimize kidney lesions and the systemic inflammatory response, thereby decreasing acute kidney injury (AKI) incidence. METHODS: In this double-blinded randomized control study, 80 patients admitted to the ICU post-cardiac surgery were randomized by computer to receive intravenously isotonic saline (n = 40) versus α-Epoetin (n = 40): either 40000 IU (n = 20) or 20000 IU (n = 20). The study lasted one year. The primary outcome was the change in urinary NGAL concentration from baseline and 48 h after EPO injection. Creatinine, cystatine C and urinary NGAL levels were measured on the day of randomization and 2-4 days after EPO injection. To assess acute inflammatory response, serum cytokines (IL6 and IL8) were measured at randomization and four days after r-HuEPO injection. Patients and care-takers were blinded for the assignment. RESULTS: No patient was excluded after randomization. Patient groups did not differ in terms of age, gender, comorbidities and renal function at randomization. The rate of AKI assessed by AKIN criteria was 22.5% in our population. EPO treatment did not significantly modify the difference in uNGAl between 48 hours and randomization compared to placebo [2.5 ng/ml (-17.3; 22.5) vs 0.7 ng/ml (-31.77; 25.15), p = 0.77] and the incidence of AKI was similar. Inflammatory cytokines levels were not influenced by EPO treatment. Mortality and hospital stays were similar between the groups and no adverse event was recorded. CONCLUSION: In this randomized-controlled trial, α-Epoetin administrated after cardiac surgery, although safe, demonstrated neither nephroprotective nor anti-inflammatory properties. TRIAL REGISTRATION NUMBER: NCT00676234.

ScvO(2) as a marker to define fluid responsiveness.

BACKGROUND: Definition of the hemodynamic response to volume expansion (VE) could be useful in shocked critically ill patients in absence of cardiac index (CI) measurements. The aim of this study is to evaluate whether central venous oxygen saturation variations (ΔScvO(2)) after VE could be an alternative to classify responders (R) and nonresponders (NR) to volume therapy. METHODS: A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO(2)) and ScvO(2) were measured before and after VE. CI, SvO(2), and ScvO(2) changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR. RESULTS: ΔScvO(2) and SvO(2) variations after VE (ΔSvO(2)) were significantly correlated with CI changes (ΔCI) after VE (r = 0.67 and r = 0.49, p < 0.001, respectively). A ΔScvO(2) threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 57-98%) and 81% specificity (95%CI; 54-96%). CONCLUSIONS: ScvO2 variations after VE was able to categorize VE efficiently and could be suggested as an alternative marker to define fluid responsiveness in absence of invasive CI measurement.

Influence of tidal volume on pulse pressure variations in hypovolemic ventilated pigs with acute respiratory distress-like syndrome.

BACKGROUND: Sensitivity and specificity of respiratory change in pulse pressure (DeltaPP) to predict preload dependency has been questioned at small tidal volumes (VT) in critically ill patients suffering from acute respiratory distress syndrome (ARDS). We studied DeltaPP in pigs with ARDS-like syndrome during reversible hemorrhagic shock. METHODS: Prospective, observational animal study in a Laboratory Investigation Unit. Sixteen deeply sedated mechanically ventilated pigs were successively ventilated with VT of 10 ml/kg at a respiratory rate of 15 breaths/min (RR15) and VT of 6 ml/kg at RR15 and RR25. ARDS-like syndrome was produced by lung lavage in eight pigs (ARDS group). Severe hemorrhagic shock was induced by removal of 40% of total blood volume followed by restoration. RESULTS: After bleeding, in the control group ventilated with a VT of 10 ml/kg, DeltaPP increased from 8.5 (95% confidence interval [CI], 7.1 to 9.9%) to 18.5% (CI, 15.3 to 21.7%; P<0.05). In the ARDS group, this index increased similarly, from 7.1% (95% CI, 5.3 to 9.0%) to 20.1% (CI, 15.3 to 24.9%; P<0.05). In control lungs, reduction in VT from 10 to 6 ml/kg reduced the DeltaPP reaction by 40%, although it remained a statistically valid indicator of hypovolemia regardless of the RR value. In contrast, in the ARDS group, DeltaPP was an unreliable hypovolemia marker at low VT ventilation, regardless of the RR value (p=not statistically significant). CONCLUSIONS: The present study suggests that DeltaPP is a reliable indicator of severe hypovolemia in pigs with healthy lungs regardless of VT or RR. In contrast, in pigs with ARDS-like syndrome ventilated with small VT, DeltaPP is not a good indicator of severe hemorrhage. However, in this setting, indexing DeltaPP to respiratory changes in transpulmonary pressure allows this marker to significantly indicate the occurrence of hypovolemia.

Atrial and brain natriuretic peptide concentrations and the response to inhaled nitric oxide in patients with acute respiratory distress syndrome.

PURPOSE: The response to inhaled nitric oxide (iNO) is inconsistent in patients with acute respiratory distress syndrome (ARDS). We sought to determine whether the response to iNO, defined as 20% Pao(2)/Fio(2) increase from baseline, depends on the level of cardiac natriuretic peptides. MATERIALS AND METHODS: This is a prospective cohort study including 11 consecutive patients with ARDS who were eligible to receive iNO. Measurements of plasma concentrations of atrial natriuretic peptide (ANP), N-Terminal-Pro-B-Type Natriuretic Peptide (NT-pro-BNP) and 3',5'-cyclic guanosine monophosphate were obtained before initiating iNO and 30 minutes later during iNO. Baseline cardiac peptides, oxygenation, and hemodynamic variables and their change during iNO were compared among responders and nonreponders to iNO. RESULTS: Baseline ANP and NT-pro-BNP concentrations were higher in patients that responded to iNO and tended to decrease during iNO in responders only. 3',5'-Cyclic guanosine monophosphate concentrations were not different among responders and nonresponders and were unchanged during iNO. Baseline ANP was strongly correlated with change in intrapulmonary shunt, and baseline NT-pro-BNP and its change were correlated with the change in cardiac output. CONCLUSIONS: High ANP and NT-pro-BNP concentrations are associated with the response to iNO. These data suggest that cardiac peptides have the potential to identify a subgroup of patients with ARDS who might derive clinical benefit from iNO.

Randomized trial of light versus deep sedation on mental health after critical illness.

OBJECTIVES: : To investigate if light sedation favorably affects subsequent patient mental health compared with deep sedation. Symptoms of posttraumatic stress disorder are common in patients after they have undergone prolonged mechanical ventilation and are associated with sedation depth. DESIGN: : Randomized, open-label, controlled trial. SETTING: : Single tertiary care center. PATIENTS: : Adult patients requiring mechanical ventilation. INTERVENTIONS: : Patients were randomized to receive either light (patient awake and cooperative) or deep sedation (patient asleep, awakening upon physical stimulation). MEASUREMENTS AND MAIN RESULTS: : Self-reported measures of posttraumatic stress disorder, anxiety, and depression were collected at intensive care unit discharge and 4 wks later. The primary outcomes were symptoms of posttraumatic stress disorder, anxiety, and depression 4 wks after intensive care unit discharge.A total of 137 patients were assigned to either the light (n = 69) or the deep sedation (n = 68) group. Seven patients withdrew consent and one patient was randomized in error, leaving 129 patients (n = 65 in light sedation and n = 64 in deep sedation) available for analysis. At the 4-wk follow-up, patients in the deep sedation group tended to have more posttraumatic stress disorder symptoms (p = .07); the deep sedation group had more trouble remembering the event (37% vs. 14%; p = .02) and more disturbing memories of the intensive care unit (18% vs. 4%; p = .05). Patients in the light sedation group had an average one day less being ventilated and 1.5 fewer days in the intensive care unit. There were no differences between the two groups in the occurrence of anxiety and depression, and also no difference in mortality or in the incidence of adverse events. CONCLUSIONS: : These data suggest that a strategy of light sedation affords benefits with regard to reduction of intensive care unit stay and duration of ventilation without negatively affecting subsequent patient mental health or patient safety.

Differences in critical care practice between an industrialized and a developing country.

BACKGROUND: Few data are available on intensive care unit (ICU) patient populations and critical care medicine practices in developing countries. METHODS: This prospective study evaluated differences in patient characteristics, ICU practice, and outcome between the ICUs of a Mongolian 400-bed tertiary university hospital (MonICU) and an Austrian 429-bed secondary hospital (AutICU). Demographics, chronic health status, clinical parameters, disease and therapeutic severity scores, and outcome were documented for all patients admitted to the two ICUs during a period of four and a half months. Standard tests and multiple regression analysis were used for statistical analysis. RESULTS: A total of 203 critically ill patients were admitted to MonICU and 257 to AutICU. MonICU patients had fewer chronic diseases than AutICU patients (0.9 +/- 0.8 vs. 2.7 +/- 1.5, P < 0.001) but more frequently suffered from tuberculosis (2.5% vs. 0%, P = 0.01) and more frequently had never been medically examined before ICU admission (10.8% vs. 0%, P < 0.001). Admission diagnoses differed both in type and relative proportions in the two ICUs (P < 0.001). Admission of MonICU patients was more frequently unplanned (69% vs. 50.2%, P < 0.001), and although disease was more severe in these patients they received fewer therapeutic interventions than the AutICU patients. Overall mortality was higher in the MonICU patients (19.7 vs. 6.2%, P < 0.001). CONCLUSIONS: Patient characteristics and ICU practices varied significantly between the two ICUs. Mortality was substantially greater at MonICU, particularly among patients suffering from multiple-organ dysfunction. Strategies to improve the care of critically ill patients at MonICU should address both system- and staff-related problems, improve acceptance of the ICU service among physicians of other disciplines and upgrade the training of ICU staff.

Reducing pain in patients undergoing cardiac surgery after implementation of a quality improvement postoperative pain treatment program.

PURPOSE: The aim of this study was to test the effectiveness of a quality improvement postoperative pain treatment program after cardiac surgery. MATERIALS AND METHODS: This was a prospective, quasiexperimental study using nonequivalent groups comprising 3 periods: baseline (group baseline), implementation of the algorithm for acute pain management, and reassessment (group reassessment). Inclusion of 133 patients after elective cardiac surgery at an 18-bed surgical intensive care unit (SICU) at a Swiss university hospital. The algorithm was implemented by training, pocket guidelines, regular audits, and feedback. The implementation period was completed when the adherence to 2 of 3 process indicators attained at least 70% over 2 months. Visual analog scales (VAS) for pain, morphine consumption, pain perception, and sleep quality were assessed during stay in SICU and after 1 month and 6 months. RESULTS: The assessment included 79 patients at baseline and 54 in the reassessment periods. Pain intensity at rest decreased from 2.7 +/- 1.4 to 2.2 +/- 1.4 cm (VAS; P = .008). Retrospective perception of pain intensity at rest decreased from 3.8 +/- 2.2 to 2.6 +/- 1.8 (P = .004). The proportion of patients with no pain or often without pain increased from 11% to 37% (P = .005). The number of patients with sleep disturbances decreased from 68% to 35% (P = .012). No differences were observed at 1 and 6 months postoperatively. CONCLUSIONS: After algorithm implementation in the SICU, pain intensity at rest decreased and quality of sleep improved.

Long intraaortic balloon treatment time leads to more vascular complications.

Intraaortic balloon counterpulsation is an established and efficient therapy. Limb ischemia is the most common complication. The impact of treatment duration on balloon-related complications was analyzed retrospectively in 135 patients who underwent balloon counterpulsation between 1998 and 2004. Thirty high-risk coronary patients required preoperative intraaortic balloon therapy, 41 were in preoperative cardiogenic shock, and 64 needed support for difficulties in weaning from cardiopulmonary bypass. No balloon-related mortality occurred. The overall balloon-related complication rate was 20/135 (14.8%); 18 had limb ischemia, of whom 6 (4.4%) required vascular interventions. Intraaortic balloon treatment time was significantly longer in patients who developed limb ischemia (99.8 +/- 54.1 h) compared to those who did not (34.4 +/- 30.4 h). Preoperative therapy had short treatment times and few complications. Intraaortic balloon pumping provides effective circulatory support with a low complication rate. A clear relationship was established between duration of treatment and balloon-related complications. Independent risk factors for balloon-related complications were long treatment time, acute myocardial infarction, age over 65 years, and ejection fraction less than 0.30.

Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review.

INTRODUCTION: Raised intracranial pressure (ICP) has been consistently associated with poor neurological outcome. Our purpose was to systematically review the literature to estimate the association between ICP values and patterns and short- and long-term vital and neurological outcome. METHODS: Systematic review of studies identified from MEDLINE, EMBASE, and COCHRANE Registry search from 1966 to 2005, and reference lists of identified articles, with independent assessment of methodological quality, population, ICP values and patterns, management of raised ICP and neurological outcomes. Summary odds ratios (OR) were calculated for the main outcomes using proportional odds models and logistic regression. RESULTS: Four prospective studies (409 patients) reported the effect of ICP values, and five studies (677 patients) reported the effect of ICP patterns on neurological outcome. No study reported neurological outcomes beyond 1 year. Relative to normal ICP (<20 mmHg), raised ICP was associated with elevated OR of death: 3.5 [95%CI: 1.7, 7.3] for ICP 20-40, and 6.9 [95%CI: 3.9, 12.4] for ICP>40. Raised but reducible ICP was associated with a 3-4-fold increase in the OR of death or poor neurological outcome. Refractory ICP pattern was associated with a dramatic increase in the relative risk of death (OR 114.3 [95%CI: 40.5, 322.3]). CONCLUSIONS: Refractory ICP and response to treatment of raised ICP could be better predictors of neurological outcome than absolute ICP values. Limitations in the design of the studies analyzed precluded identification of the role of ICP monitoring in predicting short- and long-term outcomes.

Is it now time to promote mixed enteral and parenteral nutrition for the critically ill patient?

BACKGROUND: Intensive care outcome measured by morbidity and mortality is altered in the severely malnourished ICU patient, and nutritional support of the critically ill is accepted as a standard of care. Current recommendations suggest starting enteral feeding as soon as possible whenever the gastrointestinal tract is functioning. The disadvantage of enteral support is that inadequate energy and protein intake can occur. The present commentary focuses on some recent findings regarding the nutritional support of critically ill patients and proposes to promote mixed nutrition support by enteral nutrition (EN), and by parenteral nutrition (PN) whenever EN is insufficient. RECENT FINDINGS: An increasing nutrition deficit during a long ICU stay is associated with increased morbidity (increased infection rate or impaired wound healing). Evidence shows that EN can result in underfeeding and that nutrition goals are reached only after 5-7 days. Contrary to former beliefs, recent meta-analyses of studies in the ICU showed that PN is not related to excess mortality but may even be associated with improved survival. CONCLUSIONS: Optimising the increased substrate requirement for the critically ill by initiating timely nutrition support and ensuring tight glycaemic control with insulin is now considered central for improved intensive care outcomes. Supplemental PN combined with EN could be an effective alternative to achieve 100% of energy and protein targets at day 4, when EN alone fails to achieve goals greater than 60% by day 3. Whether such combined nutrition support provides additional benefit on overall outcome has to be ascertained in further studies.

Continuous cardiac output monitoring after cardiopulmonary bypass: a comparison with bolus thermodilution measurement.

OBJECTIVE: The interchangeability of continuous measurement of cardiac output (CO) with the traditional bolus method in patients after cardiopulmonary bypass (CPB) is uncertain. DESIGN: Prospective observational clinical study. SETTING: A 20-bed surgical ICU at a university hospital. PATIENTS: Fourteen deeply sedated, ventilated, post-cardiac surgery patients, all equipped with a pulmonary artery catheter. INTERVENTIONS: Six hours after the end of the CPB, 56 simultaneous bolus and continuous measurements were compared by a linear regression analysis and Bland-Altman analysis. Bolus CO was estimated by averaging triplicate injections of 10 ml room-temperature NaCl 0.9%, delivered randomly during the respiratory cycle. A stringent maximum difference of 0.55 l min(-1) (about 10% of the mean bolus measured) was considered as a clinically acceptable agreement between the two types of measurements. To be interchangeable the limits of agreement (+/-2 SD of the mean difference between the two methods) should not exceed the chosen acceptable difference. MEASUREMENTS AND RESULTS: Continuous was correlated with bolus CO, with a correlation coefficient of r(2)=0.68. (p<0.01). The Bland-Altman analysis demonstrated an objective mean bias of 0.33+/-0.6 l min(-1) (confidence interval of -0.87-1.58) with 34% of measured values falling outside of the clinically acceptable limits. CONCLUSION: Our results suggest that, in the first 6 h after CPB, continuous and bolus CO determinations are not interchangeable; one third of the values obtained by continuous CO fell outside the strict limits of clinically useful precision.

Fluid responsiveness in spontaneously breathing patients: a review of indexes used in intensive care.

OBJECTIVE: In spontaneously breathing patients, indexes predicting hemodynamic response to volume expansion are very much needed. The present review discusses the clinical utility and accuracy of indexes tested as bedside indicators of preload reserve and fluid responsiveness in hypotensive, spontaneously breathing patients. DATA SOURCE: We conducted a literature search of the MEDLINE database and the trial register of the Cochrane Group. STUDY SELECTION: Identification of reports investigating, prospectively, indexes of fluid responsiveness in spontaneously breathing critically ill patients. All the studies defined the response to fluid therapy after measuring cardiac output and stroke volume using the thermodilution technique. We did not score the methodological quality of the included studies before the data analysis. DATA EXTRACTION: A total of eight prospective clinical studies in critically ill patients were included. Only one publication evaluated cardiac output changes induced by fluid replacement in a selected population of spontaneously breathing critically ill patients. DATA SYNTHESIS: Based on this review, we can only conclude that static indexes are valuable tools to confirm that the fluid volume infused reaches the cardiac chambers, and therefore these indexes inform about changes in cardiac preload. However, respiratory variation in right atrial pressure, which represents a dynamic measurement, seems to identify hypotension related to a decrease in preload and to distinguish between responders and nonresponders to a fluid challenge. CONCLUSIONS: Further studies should address the question of the role of static indexes in predicting cardiac output improvement following fluid infusion in spontaneously breathing patients.

Infection and rejection in liver transplant patients: a 10-year Swiss single-centre experience.

INTRODUCTION: Graft rejection and infection remain major morbidities following orthotopic liver transplantation (OLT). Rejection treatment may be associated with an increased rate of infectious complications. The aim of this study was to determine the relationship between rejection, rejection therapy and the risk of associated infections. MATERIALS AND METHODS: A retrospective study of all adult patients undergoing OLT between July 1987 and July 1997 at a single university medical centre was carried out. Data for all transplant recipients were collected using predetermined definitions for infectious complications. RESULTS: One hundred OLTs were performed on 98 patients (two patients received a second transplant). The cohort consisted of 33 women and 65 men with a mean age of 47 years. Seventy-eight patients developed a total of 228 infectious episodes: 107 bacterial, 101 viral, 17 fungal and 3 protozoan. The majority of infections occurred within the first month of OLT. Thirty patients without rejection developed 42 infectious episodes, whereas 70 patients with at least one treated rejection episode developed 186 infectious episodes. The overall rate of infection was 44.4 episodes per 1000 patient-days in the 30 days before rejection, and 94.4 episodes per 1000 patient-days in the 30 days following rejection treatment. CONCLUSIONS: Infections occurred more frequently during the first month post-transplantation. Following OLT, rejection is associated with a higher incidence of infection, mainly of viral origin, concurrent with increased immunosuppressive therapy.

Misplacement of central vein catheters in patients with hemothorax: a new approach to resolve the problem.

BACKGROUND: In emergency and pre-hospital care, the verification of the correct position of a central venous catheter is based on the observation of blood color reflow as well as pressure changes with respiration. However, in trauma patient with hemothorax, these indices may not always be reliable signs as the catheter is in a blood-filled pleural space. METHODS: A review of reports published describing patients presenting hemothorax and equipped with central venous catheter wrongly assumed to be in the correct position was performed. RESULTS: Over 10 years, seven reports have been published and a last study was found in the references list of one of the reviews. CONCLUSION: In patients with hemothorax due to severe thoracic trauma or other causes, a delay in detection of incorrect placement of a central venous catheter may delay fluid resuscitation and decrease the chances of survival. In this situation, the use of portable ultrasound devices may be an useful method to increase success rate in catheter insertion.

A nationwide survey of intensive care unit discharge practices.

OBJECTIVE: To describe intensive care unit (ICU) discharge practices, examine factors associated with physicians' discharge decisions, and explore ICU and hospital characteristics and clinical determinants associated with the discharge process. DESIGN: Survey in adult ICUs affiliated with the Swiss Society of Intensive Care Medicine. INTERVENTIONS: Questionnaire inquiring about ICU structure and organization mailed to 73 medical directors. Level of monitoring, intravenous medications, and physiological variables were proposed as elements of discharge decision. Five clinical situations were presented with request to assign a discharge disposition. MEASUREMENTS AND RESULTS: Fifty-five ICUs participated, representing 75% of adult Swiss ICUs. Responsibility for patient management was assigned in 91% to the ICU team directing patient care. Only 22% of responding centers used written discharge guidelines. One-half of the respondents considered at least 10 of 15 proposed criteria to decide patient discharge. ICUs in central referral hospitals used fewer criteria than community and private hospitals. The availability of intermediate care units was significantly greater in university hospitals. The ICU director's level of experience was not associated with the number of criteria used. In the five clinical scenarios there was wide variation in discharge decision. CONCLUSIONS: Our data indicate that there is marked heterogeneity in ICUs discharge practices, and that discharge decisions may be influenced by institutional factors. University teaching hospitals had more intermediate care facilities available. Written discharge guidelines were not widely used.

Transcutaneous PCO2 monitoring in critically ill adults: clinical evaluation of a new sensor.

OBJECTIVE: In critically ill patients, arterial blood gas analysis is the gold standard for evaluating systemic oxygenation and carbon dioxide partial pressure. A new miniaturized carbon dioxide tension Pco2-Spo2 single sensor (TOSCA, Linde Medical Sensors AG, Basel, Switzerland) continuously and noninvasively (transcutaneously) monitors both Paco2 and oxygen saturation by pulse oximetry (Spo2). The present study was designed to investigate the usability and the accuracy of this device in critically ill patients. DESIGN: Prospective clinical investigation. SETTING: A 20-bed, university-affiliated, surgical intensive care unit. PATIENTS: Patients admitted after major surgery, multiple trauma, or septic shock equipped with an arterial catheter. INTERVENTIONS: The heated (42 degrees C) sensor was fixed at the earlobe using an attachment clip. Transcutaneous Pco2 (TcPco2) measurements were correlated with Paco2 values (measured using a blood gas analyzer). In addition, the differences between Paco2 and TcPco2 values were evaluated using the method of Bland-Altman. MEASUREMENTS AND MAIN RESULTS: We studied 55 patients, aged 18-80 (mean 57 +/- 15) yrs. A total of 417 paired measurements were compared. Correlation between TcPco2 and Paco2 was r = .86 (p < .01) in the Paco2 range of 24-101 mm Hg. Mean bias (+/-sd) between the two methods of measurement (Bland-Altman analysis) was 1.2 +/- 6.0 mm Hg with TcPco2 slightly overestimating arterial carbon dioxide tension. Nineteen percent of the measured values were outside of the acceptable clinical range of agreement of +/-7.5 mm Hg. CONCLUSIONS: The present study suggests that Paco2 can be acceptably assessed by measuring TcPco2 using the TOSCA Pco2-Spo2 sensor.

Management of the critically ill patient with severe acute pancreatitis.

OBJECTIVE: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS: An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS: There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS: This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.

Higher calorie prescription improves nutrient delivery during the first 5 days of enteral nutrition.

AIMS: It is unclear whether prescribing a higher amount of calories by enteral nutrition (EN) increases actual delivery. This prospective controlled study aimed at comparing the progression of EN of two study populations with different levels of calorie prescriptions, during the first 5 days of EN. METHODS: The daily calorie prescription of group 1 (n=346) was 25 and 20 kcal/kg body weight for women <60 and > or =60 years, respectively, and 30 and 25 kcal/kg body weight for men <60 and > or =60 years, respectively. The prescription of group 2 (n=148) was 5 kcal/kg body weight higher than in group 1. Calorie intakes were expressed as percentage of resting energy expenditure (REE) and protein intakes as percentage of requirements estimated as 1.2 g/kg body weight/day. Patients were classified as <60 and > or =60 years and as medical or surgical patients. Statistical analysis was performed with ANOVA for repeated measures. RESULTS: Calorie and protein deliveries increased in both groups independently of age and ward categories (P< or =0.0001). Group 2 showed faster progressions of calorie and protein intakes than group 1 in patients altogether (P< or =0.002), > or =60 years (P< or =0.01) and in surgical patients (P< or =0.02). Differences of calorie and protein intakes between day 1 and day 5 were significantly higher in group 2 than group 1 for patients altogether (75+/-61 vs. 56+/-54% of REE; 41+/-30 vs. 31+/-/-27% of protein requirements), those over 60 years (76+/-67 of REE vs. 52+/-59 of protein requirements) and surgical patients (81+/-52 vs. 58+/-57% of REE; 44+/-27 vs. 33+/-29% of protein requirements). CONCLUSIONS: Increasing the levels of EN prescriptions improved calorie and protein deliveries. While the mean energy delivery over 5 days was sufficient to cover requirements, the protein delivery by EN was insufficient, despite our nutritional support team.