Novel Tools to Assess Muscle Sarcopenic Process in ICU Patients: Are They Worthwhile?

Critical illness induces hypercatabolic response with severe loss of lean body mass, this being a key symptom in patients with prolonged ICU stay and is associated with acquired muscle weakness, long-term mechanical ventilation, fatigue, delayed recovery, and poor quality of life after ICU stay [...].

[El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (I)]. / El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (I).

Introduction: El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (I).

Introducción: El reto de evaluar la situación nutricional de los pacientes y su evolución durante el tratamiento. Desde el paciente crítico hasta el paciente ambulatorio (I).

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study.

BACKGROUND: Hypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl-) and mortality in incident chronic hemodialysis (HD) patients. METHOD: Retrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan-Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure. RESULTS: During the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl- and interdialytic weight gain (r=-0.15) (p=0.0038). Patients belonging to the quartile with lower Cl- levels had less probability of survival than patients in the quartile with higher Cl- levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl- levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77-0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83-0.97; p<0.0057). CONCLUSIONS: Lower Cl- levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance. METHODS: Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001). CONCLUSION: The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.

COVID-19 Secondary Infections in ICU Patients and Prevention Control Measures: A Preliminary Prospective Multicenter Study.

The incidence of secondary infections in critically ill coronavirus disease 2019 (COVID-19) patients is worrisome. We investigated whether selective digestive decontamination (SDD) added to infection control measures during an intensive care unit (ICU) stay modified these infection rates. Methods: A retrospective observational cohort study was carried out in four ICUs in Spain. All consecutive ventilated patients with a SARS-CoV-2 infection engaged in national infection control programs between 1 March and 10 December 2020 were investigated. Patients were grouped into two cohorts according to the site of ICU admission. Secondary relevant infections were included. Infection densities corresponding to ventilator-associated pneumonia (VAP), catheter bacteremia, secondary bacteremia, and multi-resistant germs were obtained as the number of events per 1000 days of exposure and were compared between SDD and non-SDD groups using Poisson regression. Factors that had an independent association with mortality were identified using multidimensional logistic analysis. Results: There were 108 patients in the SDD cohort and 157 in the non-SDD cohort. Patients in the SDD cohort showed significantly lower rates (p < 0.001) of VAP (1.9 vs. 9.3 events per 1000 ventilation days) and MDR infections (0.57 vs. 2.28 events per 1000 ICU days) and a non-significant reduction in secondary bacteremia (0.6 vs. 1.41 events per 1000 ICU days) compared with those in the non-SDD cohort. Infections caused by MDR pathogens occurred in 5 patients in the SDD cohort and 21 patients in the non-SDD cohort (p = 0.006). Differences in mortality according to SDD were not found. Conclusion: The implementation of SDD in infection control programs significantly reduced the incidence of VAP and MDR infections in critically ill SARS-CoV-2 infected patients.

Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida? / Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose?

Introducción : La inflamación crónica y la subyacente comorbilidad cardiovascular aún son problemas vigentes en los pacientes en hemodiálisis crónica. Existen pocos estudios que comparen la «dosis de diálisis» (Kt/V) con el grado de inflamación del paciente. Nuestro objetivo principal fue determinar si existe una relación entre los niveles séricos de proteína C reactiva (PCR) y el Kt/V utilizando la dialisancia iónica.Métodos : Estudio transversal multicéntrico. Se incluyeron 536 pacientes prevalentes en hemodiálisis crónica. Se recogieron los niveles de PCR, el índice neutrófilo-linfocito y el índice plaqueta-linfocito. Se obtuvo el Kt por dialisancia iónica y el volumen de distribución de la urea mediante la fórmula de Watson. Se dividió la muestra en 2 grupos tomando como punto de corte la mediana de PCR y se comparó la adecuación de diálisis en cada uno. Finalmente, se realizó un modelo de regresión logística para determinar las variables de mayor influencia.Resultados : La mediana de PCR fue 4,10mg/L (q25-q75: 1,67-10). El Kt/V medio fue de 1,48±0,308. El Kt/V fue menor en los pacientes incluidos en el grupo de inflamación alta (p=0,01). En la regresión logística multivariante, los niveles «altos» de PCR tuvieron una correlación directa con el Log índice neutrófilo-linfocito (p<0,001) e inversamente proporcional con los valores de albúmina sérica (p=0,014), Kt/V (p=0,037) y hierro sérico (p<0,001).Conclusión : La peor adecuación en términos de dosis de diálisis (valores de Kt/V más bajos) puede contribuir a un mayor grado de inflamación en los pacientes en hemodiálisis crónica. (AU)

Introduction : Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the “dialysis dose” (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance.Methods : Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.Results : Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the “high” levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001).Conclusion : The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients. (AU)

Novel High-Quality Sonographic Methods to Diagnose Muscle Wasting in Long-Stay Critically Ill Patients: Shear Wave Elastography, Superb Microvascular Imaging and Contrast-Enhanced Ultrasound.

Novel ultrasound (US) methods are required to assess qualitative changes in the quadriceps rectus femoris (QRF) muscle when evaluating mechanically ventilated, long-stay ICU patients with suspected neuromuscular acquired weakness (ICUAW). Our aim was to analyze novel US muscle assessment methods in these patients versus healthy controls by carrying out a prospective observational study. Shear wave elastography (SWE) showed, with a receiver operating characteristic (ROC) curve of 0.972 (95% confidence interval (CI) = 0.916-1.000), that patients increased muscle stiffness associated with muscle fibrosis when diagnosed with ICUAW. We also performed, for the first time, superb microvascular imaging (SMI), which is an innovative US technique designed for imaging microvascularization unseen with color Doppler US, and observed that 53.8% of cases had significantly lower QRF muscle microvascular angiogenic activity than controls (p < 0.001). Finally, we used contrast-enhanced ultrasound (CEUS) to analyze maximum and minimum QRF muscle perfusion and obtained a ROC curve of 0.8, but when used as markers for SMI, their diagnostic capacity increased to 0.988 (CI = 0.965-1) and 0.932 (CI = 0.858-1), respectively. These findings show, for the first time, that these novel sonographic muscle methods should be used for their diagnostic capacity when assessing sarcopenic processes associated with this group of critically ill patients.

Inflammation and hemodialysis adequacy: Are C-reactive protein levels influenced by dialysis dose? / Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance. METHODS: Multicenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48±0.308. Kt/V was lower in the patients included in the high inflammation group (P=.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P<.001) and inversely proportional with serum albumin values (P=.014), Kt/V (P=.037) and serum iron (P<.001). CONCLUSION: The poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis.

OBJECTIVE: To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults. DESIGN: A 5-year prospective cohort study. SETTING: Tertiary-care teaching hospital in Seville, Spain. PATIENTS: Adult patients undergoing PICC insertion. METHODS: Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis. RESULTS: In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications. CONCLUSIONS: PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

Assessment of Muscle Wasting in Long-Stay ICU Patients Using a New Ultrasound Protocol.

There is currently no standardized procedure to assess sarcopenia in long-stay catabolic patients. Our aim is to analyze a novel ultrasound muscle assessment protocol in these patients versus healthy controls, by carrying out a prospective observational study. We designed a new ultrasound protocol that assesses quadriceps rectus femoris (QRF) muscle quality in real-time B-mode, color-Doppler, and M-mode ultrasound, and evaluates QRF intramuscular central tendon thickness, cross-sectional area, and muscle thickness in ultrasound B-mode. Logistic regression was performed as a multivariable analysis on 29 cases and 19 controls. The QRF muscle area and thickness were shown to significantly decrease (p ≤ 0.001), and the central tendon thickness significantly increased (p = 0.047) in cases versus controls. The QRF muscle echogenicity and angiogenic activity fasciculations, subcutaneous edema, and intramuscular fluid were also significantly different between the two groups (p < 0.001). The selected variables in the multivariate logit analysis were the muscle area (OR per cm² = 0.07; 95% confidence interval (CI) = 0.012⁻0.41) and the central tendon thickness (OR per mm 1.887; 95% CI = 2.66⁻13.38).

[Critically ill patient enteral nutrition in the 21st century]. / Nutrición enteral del paciente crítico en el siglo XXI.

In order to make estimations on the evolution and near future of enteral nutrition in critically ill adult patients, we have revised the current clinical practices based on the latest guidelines for the provision and assessment of enteral nutrition support therapy. Once revised the suggested guideline recommendations we proceed to discuss the major recently published studies concerning these guidelines. Finally, we commented on several uncertainty areas highlighting priorities for clinical research in the near future. These uncertainty areas were as follows: administration methods of enteral nutrition, gastric residual volume monitorization, other aspects of gastrointestinal tolerance, protein requirements, glycemic monitorization and diabetic specific diets, immune-modulating formulas, permissive underfeeding or trophic enteral nutrition, supplementary nutrition and muscle wasting.

Para hacer estimaciones de cómo evolucionará la nutrición enteral en el siglo xxihemos partido de las prácticas hospitalarias vigentes en la actualidad, estructuradas en las denominadas guías de práctica clínica, de uso más habitual en el paciente crítico adulto. Desde las recomendaciones de estas guías procedimos a comentar los avances y publicaciones más recientes concernientes a dichas prácticas. Posteriormente se discutirán algunas de las áreas de indefinición más trascendentales y las perspectivas futuras a lo largo de este siglo recién estrenado. Estas áreas son: método de administración de la nutrición enteral, monitorización del volumen residual gástrico, otros aspectos de la tolerancia gastrointestinal, necesidades proteicas, monitorización de la glucemia y fórmulas específicas para diabetes, dietas de inmunomodulación, nutrición con hipoalimentación permisiva o trófica, nutrición suplementaria y pérdida muscular.

Long-term use of selective digestive decontamination in an ICU highly endemic for bacterial resistance.

BACKGROUND: We examined whether long-term use of selective digestive tract decontamination (SDD) was effective in reducing intensive care unit (ICU)-acquired infection and antibiotic consumption while decreasing colistin-, tobramycin-, and most of the antibiotic-resistant colonization rates in a mixed ICU with a high endemic level of multidrug-resistant bacteria (MDRB). METHODS: In this cohort study, which was conducted in a 30-bed medical-surgical ICU, clinical outcomes before (1 year, non-SDD group) and after (4 years) implementation of SDD were compared. ICU patients who were expected to require tracheal intubation for > 48 hours were given a standard prophylactic SDD regimen. Oropharyngeal and rectal swabs were obtained on admission and once weekly thereafter. RESULTS: ICU-acquired infections occurred in 110 patients in the non-SDD group and in 258 in the SDD group. A significant (P <  0.001) reduction of infections caused by MDRB (risk ratio [RR], 0.31; 95% CI, 0.23-0.41) was found after SDD and was associated with low rates of colistin- and tobramycin-resistant colonization. Colistin- and tobramycin-acquired increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at admission, was nonsignificant (0.82; 95% CI, 0.56 to 1.95; 1.13; 95% CI, 0.75 to 1.70, respectively). SDD was also a protective factor for ICU-acquired infections caused by MDR gram-negative pathogens and Acinetobacter baumannii in the multivariate analysis. In addition, a significant (P <  0.001) reduction of ventilator-associated pneumonia (VAP) (RR, 0.43; 95% CI, 0.32-0.59) and secondary bloodstream infection (BSI) (RR, 0.35; 95% CI, 0.24-0.52) was found. A decrease in antibiotic consumption was also observed. CONCLUSIONS: Treatment with SDD during 4 years was effective in an ICU setting with a high level of resistance, with clinically relevant reductions of infections caused by MDRB, and with low rates of colistin- and tobramycin-resistant colonization with nonsignificant increasing rate of ICU colonization resistance by 1000 days, adjusted by the rate of resistances at ICU admission. In addition, VAP and secondary BSI rates were significantly lower after SDD. Notably, a decrease in antimicrobial consumption was also observed.

Nutrición enteral del paciente crítico en el siglo XXI / Critically ill patient enteral nutrition in the 21st century

Para hacer estimaciones de cómo evolucionará la nutrición enteral en el siglo xxi hemos partido de las prácticas hospitalarias vigentes en la actualidad, estructuradas en las denominadas guías de práctica clínica, de uso más habitual en el paciente crítico adulto. Desde las recomendaciones de estas guías procedimos a comentar los avances y publicaciones más recientes concernientes a dichas prácticas. Posteriormente se discutirán algunas de las áreas de indefinición más trascendentales y las perspectivas futuras a lo largo de este siglo recién estrenado. Estas áreas son: método de administración de la nutrición enteral, monitorización del volumen residual gástrico, otros aspectos de la tolerancia gastrointestinal, necesidades proteicas, monitorización de la glucemia y fórmulas específicas para diabetes, dietas de inmunomodulación, nutrición con hipoalimentación permisiva o trófica, nutrición suplementaria y pérdida muscular

In order to make estimations on the evolution and near future of enteral nutrition in critically ill adult patients, we have revised the current clinical practices based on the latest guidelines for the provision and assessment of enteral nutrition support therapy. Once revised the suggested guideline recommendations we proceed to discuss the major recently published studies concerning these guidelines. Finally, we commented on several uncertainty areas highlighting priorities for clinical research in the near future. These uncertainty areas were as follows: administration methods of enteral nutrition, gastric residual volume monitorization, other aspects of gastrointestinal tolerance, protein requirements, glycemic monitorization and diabetic specific diets, immune-modulating formulas, permissive underfeeding or trophic enteral nutrition, supplementary nutrition and muscle wasting

Abordaje de la candidemia y la candidiasis invasiva en el paciente crítico: papel de las equinocandinas / Candidemia and invasive candidiasis approach in critically ill patients: role of the echinocandins

Introducción. Las infecciones invasoras producidas por Candida spp. en pacientes críticos pueden empeorar considerablemente su pronóstico, por lo que es de gran importancia establecer una detección precoz y una estrategia terapéutica adecuada. El objetivo de este estudio ha sido definir el papel diferencial de las equinocandinas para tratar determinados perfiles de pacientes críticos. Metodología. Un comité científico formado por 9 expertos en enfermedades infecciosas, cuidados críticos, microbiología y farmacia hospitalaria revisó la evidencia existente sobre el tratamiento de la candidemia y la candidiasis invasiva en pacientes críticos. Tras ello, se elaboró un cuestionario con 35 aseveraciones para ser consensuadas por 26 especialistas de las disciplinas mencionadas mediante un método Delphi modificado. Resultados. Después de dos rondas de evaluación, se alcanzó un consenso de acuerdo en el 66% de las aseveraciones. Entre los acuerdos alcanzados son: no es necesario ajustar la dosis de equinocandinas durante una terapia de reemplazo renal; las equinocandinas son el tratamiento empírico y/o dirigido de elección para la candidemia y la candidiasis invasiva asociada a biopelículas; estos fármacos pueden utilizarse en la profilaxis antifúngica del trasplante hepático de alto riesgo. En ausencia de datos clínicos adicionales, se ha de señalar que micafungina es la equinocandina con mayor evidencia científica. Conclusiones. Los expertos consultados mostraron un alto grado de acuerdo sobre algunos de los aspectos más controvertidos relativos al manejo de la candidemia y la candidiasis invasiva en pacientes críticos, lo permitiría aportar recomendaciones prácticas para su tratamiento (AU)

Introduction. Invasive infections caused by Candida spp. in critically ill patients may significantly worsen their prognosis, so it is of great importance to establish an early detection and a suitable therapeutic strategy. The objective of this study was to define the differential role of echinocandins in treating certain critical patient profiles. Methodology. A scientific committee of 9 experts in infectious diseases, critical care, microbiology, and hospital pharmacy reviewed the existing evidence on the treatment of candidemia and invasive candidiasis in critically ill patients. After that, a questionnaire with 35 items was elaborated to be agreed by 26 specialists in the aforementioned disciplines using a modified Delphi method. Results. After two rounds of evaluation, a consensus was reached in terms of agreement in 66% of the items. Some of the consensuses achieved included: it is not necessary to adjust the dose of echinocandins during renal replacement therapy; the echinocandins are the empirical and/or directed treatment of choice for candidemia and invasive candidiasis associated with biofilms; these drugs may be used in the antifungal prophylaxis of high-risk liver transplantation. In the absence of additional clinical data, it should be noted that micafungin is the echinocandin with the most available scientific evidence. Conclusions. The experts consulted showed a high degree of agreement on some of the most controversial aspects regarding the management of candidemia and invasive candidiasis in critical patients, which could inform of practical recommendations for their treatment (AU)