Long-term mortality and health-related quality of life of lower versus higher oxygenation targets in ICU patients with severe hypoxaemia.

PURPOSE: We assessed outcomes after 1 year of lower versus higher oxygenation targets in intensive care unit (ICU) patients with severe hypoxaemia. METHODS: Pre-planned analyses evaluating 1-year mortality and health-related quality-of-life (HRQoL) outcomes in the previously published Handling Oxygenation Targets in the ICU trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygen of 8 kPa or 12 kPa throughout the ICU stay up to 90 days. One-year all-cause mortality was assessed in the intention-to-treat population. HRQoL was assessed using EuroQol 5 dimensions 5 levels (EQ-5D-5L) questionnaire and EQ visual analogue scale score (EQ-VAS), and analyses were conducted in both survivors only and the intention-to-treat population with assignment of the worst scores to deceased patients. RESULTS: We obtained 1-year vital status for 2887/2928 (98.6%), and HRQoL for 2600/2928 (88.8%) of the trial population. One year after randomisation, 707/1442 patients (49%) in the lower oxygenation group vs. 704/1445 (48.7%) in the higher oxygenation group had died (adjusted risk ratio 1.00; 95% confidence interval 0.93-1.08, p = 0.92). In total, 1189/1476 (80.4%) 1-year survivors participated in HRQoL interviews: median EQ-VAS scores were 65 (interquartile range 50-80) in the lower oxygenation group versus 67 (50-80) in the higher oxygenation group (p = 0.98). None of the five EQ-5D-5L dimensions differed between groups. CONCLUSION: Among adult ICU patients with severe hypoxaemia, a lower oxygenation target (8 kPa) did not improve survival or HRQoL at 1 year as compared to a higher oxygenation target (12 kPa).

Coronavirus Disease-19 (COVID-19) associated with severe acute pancreatitis: Case report on three family members.

BACKGROUND/OBJECTIVES: Abdominal pain is one of the known symptoms associated with coronavirus disease 2019. Little is known about the development of acute pancreatitis as a complication of severe acute respiratory syndrome coronavirus 2 infection. This case report describes the presentation of acute pancreatitis in two of three family members with severe COVID-19 infection. METHODS: Data were collected from three family members admitted with COVID-19 to the intensive care unit in March 2020. This study was reviewed and approved by the local data and ethics committee (31-1521-253). RESULTS: Two of the three family members were diagnosed with acute pancreatitis associated with SARS-CoV-2. Other causes of acute pancreatitis were excluded for both patients (including alcohol, biliary obstruction/gall stones, drugs, trauma, hypertriglyceridemia, hypercalcemia, and hypotension). CONCLUSIONS: These cases highlight acute pancreatitis as a complication associated with COVID-19 and underlines the importance of measuring pancreas-specific plasma amylase in patients with COVID-19 and abdominal pain.

Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial.

PURPOSE: We assessed the effects of early goal-directed nutrition (EGDN) vs. standard nutritional care in adult intensive care unit (ICU) patients. METHODS: We randomised acutely admitted, mechanically ventilated ICU patients expected to stay longer than 3 days in the ICU. In the EGDN group we estimated nutritional requirements by indirect calorimetry and 24-h urinary urea aiming at covering 100% of requirements from the first full trial day using enteral and parenteral nutrition. In the standard of care group we aimed at providing 25 kcal/kg/day by enteral nutrition. If this was not met by day 7, patients were supplemented with parenteral nutrition. The primary outcome was physical component summary (PCS) score of SF-36 at 6 months. We performed multiple imputation for data of the non-responders. RESULTS: We randomised 203 patients and included 199 in the intention-to-treat analyses; baseline variables were reasonably balanced between the two groups. The EGDN group had less negative energy (p < 0.001) and protein (p < 0.001) balances in the ICU as compared to the standard of care group. The PCS score at 6 months did not differ between the two groups (mean difference 0.0, 95% CI -5.9 to 5.8, p = 0.99); neither did mortality, rates of organ failures, serious adverse reactions or infections in the ICU, length of ICU or hospital stay, or days alive without life support at 90 days. CONCLUSIONS: EGDN did not appear to affect physical quality of life at 6 months or other important outcomes as compared to standard nutrition care in acutely admitted, mechanically ventilated, adult ICU patients. Clinicaltrials.gov identifier no. NCT01372176.

Early goal-directed nutrition in ICU patients (EAT-ICU): protocol for a randomised trial.

INTRODUCTION: Extensive weight loss has been docu-mented in intensive care unit (ICU) survivors, primarily as the result of muscle loss, leading to impaired physical function and reduced quality of life. The aim of the EAT-ICU trial is to test the effect of early goal-directed protein-energy nutrition based on measured requirements on short-term clinical outcomes and long-term physical quality of life in ICU patients. METHODS: The EAT-ICU trial is a single-centre, randomised, parallel-group trial with concealed allocation and blinded outcome assessment. A total of 200 consecutive, acutely admitted, mechanically ventilated intensive care patients will be randomised 1:1 to early goal-directed nutrition versus standard of care to show a potential 15% relative risk reduction in the primary outcome measure (physical function) at six months (two-sided significance level α = 0.05; power ß = 80%). Secondary outcomes include energy- and protein balances, metabolic control, new organ failure, use of life support, nosocomial infections, ICU- and hospital length of stay, mortality and cost analyses. CONCLUSION: The optimal nutrition strategy for ICU patients remains unsettled. The EAT-ICU trial will provide important data on the effects of early goal-directed protein-energy nutrition based on measured requirements in these patients. FUNDING: The EAT-ICU trial is funded by Copenhagen University Hospital, Rigshospitalet and Fresenius Kabi A/S and supported by The European Society for Clinical Nutrition and Metabolism (ESPEN). TRIAL REGISTRATION: Clinicaltrials.gov identifier no. NCT01372176.

Arterial waveform-analysis is of limited value in daily clinical practice in the intensive care unit.

INTRODUCTION: It is difficult to identify the patients who will respond to fluid therapy, but the arterial waveform-derived variables have reasonably predictive values for fluid responsiveness. However, the patient must fulfil a number of prerequisites for these variables to be valid. We assessed the proportion of intensive care unit (ICU) patients with shock who at the time of resuscitation fulfilled the prerequisites for using the arterial waveform-derived variables. METHODS: This was a prospective cohort study performed at six ICUs. The study included consecutive adult patients with shock (20 patients per ICU) who received fluid resuscitation on the first day of shock. The fulfilment or not of the prerequisites (sedation, sinus rhythm and controlled ventilation with tidal volumes > 7 ml/kg) was registered at the time of the first fluid resuscitation episode and at fluid resuscitation episodes during the following days. RESULTS: A total of 119 patients with a median age of 68 years (interquartile range: 56-76 years) were included. At the time of the first fluid resuscitation, 82% (95% confidence interval (CI): 74-87) of the patients had sinus rhythm, 77% (95% CI: 69-84) were sedated, 55% (95% CI: 46-65) were on controlled ventilation and 50% (95% CI: 39-61) received tidal volumes of more than 7 ml/kg. Only 23% (95% CI: 14-33) of the patients fulfilled all four prerequisites. CONCLUSIONS: Less than a quarter of the ICU patients with shock fulfilled all the prerequisites for the use of arterial waveform-derived variables to predict fluid responsiveness. Thus, these variables may be of limited use during resuscitation in the ICU.

Acute onset and rapid progression of multiple organ failure in a young adult with undiagnosed disseminated colonic adenocarcinoma.

Colourectal cancer (CRC) is the fourth most common cause of death from cancer worldwide. While rates for CRC in adults age 50 and older have been declining, incidence rates in young adults, a population routinely not screened, has been increasing. We report a rare case of high-grade CRC in a previously healthy 27-year-old man, presented to us with symptoms of increasing abdominal pain and distension. Extensive diagnostic investigation revealed hepatomegaly with multiple processes, signs of vasculitis, extensive liver necrosis, enlarged retroperitoneal and mesenteric lymph nodes, splenomegaly, ascites and multiple vein thrombosis. The patient passed away shortly after admission due to treatment-resistant tumour lysis syndrome and multiple organ failure. Biopsy results revealed disseminated adenocarcinoma of the colon, with metastases to lymph nodes, liver, lungs and pleura. CRC in younger patients tend to present at a later stage and appears to be more aggressive, with a poorer pathological differentiation.

[Prehospital management of febrile convulsions by the Mobile Emergency Care Unit in the Capital Region of Denmark]. / Feberkramper behandlet praehospitalt af Akutlaegebil--Region Hovedstaden.

INTRODUCTION: We conducted a quality assurance project of The Mobile Emergency Care Unit (MECU) in the Capital Region of Denmark when dispatched to febrile convulsions. The study focuses on prehospital treatment, comparison between prehospital and in-hospital diagnoses and parents' perceptions of their child's febrile convulsions and their satisfaction with the MECU. MATERIAL AND METHODS: The period of investigation was from March 1st 2004 to March 31st 2005. Children with a diagnosis of febrile convulsions or relevant differential diagnoses were eligible for inclusion. Children were excluded if they had already been included, if their parents had no Danish address or if the questionnaire was not returned after a reminder was sent. RESULTS: In the period of investigation, 333 children were eligible for inclusion, 290 questionnaires were sent, and 235 were returned, giving a response rate of 81%. The median age was 1 year (range: 0-7 years). In general, parents were satisfied with the MECU. Reasons of dissatisfaction are described. Most children (76%) were admitted without physician escort. A total of 37 children (16%) received diazepam therapy, of whom 15 (6%) were given intravenous diazepam. In 90% of cases, the prehospital and in-hospital diagnosis were identical. CONCLUSION: In general, parents appreciate the service provided by the MECU. Reasons of dissatisfaction are described. On several occasions, the prehospital physician administered intravenous anticonvulsants, but we discuss if the MECU should still be dispatched primarily to febrile convulsions.

[Patients' satisfaction with the Mobile Emergency Care Unit in Copenhagen]. / Brugerundersøgelse af H:S Laegeambulance.

INTRODUCTION: Patients' satisfaction with physician-staffed ambulances in Copenhagen had not previously been investigated. We therefore conducted a survey of patients' satisfaction with the Mobile Emergency Care Unit (MECU) in Copenhagen. MATERIALS AND METHODS: The period of investigation was from 1 September 2003 to 31 December 2003. Patients with a diagnosis of COPD, asthma or a cardiac disease were eligible for inclusion. Patients were excluded if they had not yet been discharged from hospital, were registered as deceased, were under the age of 18, were without a known address or had previously been included. RESULTS: During the period of investigation, 282 questionnaires were sent out; 225 were returned, for a response rate of 80%. The patients' mean age was 71 (18-99 years). On the part of 96% of the patients, the general impression of the MECU was very good or good, and 85% felt more confident when being treated by a physician in addition to the regular ambulance crew. The majority (80%) felt that the information given by the physician had been good, and 90% that the conduct of the physician had been satisfactory or better. In 11 questionnaires the patients, in their own words, described dissatisfaction with part of the MECU. In seven cases this concerned the conduct of or the information given by the ambulance crew. Most of the patients and physicians felt that the efforts of the MECU had improved the patient's condition. CONCLUSION: We conclude that in general patients are satisfied with the service provided by the MECU. They are aware of, and feel more confident when being treated by, a physician in addition to the regular ambulance crew. Reasons for dissatisfaction were the conduct of and the information given by the physician.