Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep Disturbance in the Intensive Care Unit: The ABCDEF Bundle.

It is crucial to prevent and manage intensive care unit (ICU) distress caused by a pentad of pain, agitation, delirium, immobility, and sleep disturbance (PADIS) to optimize immediate and longterm recovery and outcomes of critically ill patients. This clinical practice guideline provides an update on the prevention, management, and liberation of PADIS in adult ICU patients using an integrated, evidence-based, multidisciplinary ICU protocol: the ABCDEF bundle. ABCDEF bundle incorporates assessment, prevention, and management of pain; both spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT); choice of sedation and analgesia; delirium: assessment, prevention and management, and early mobility and exercise; family involvement and empowerment (ABCDEF) together as a PADIS care bundle. This is a multidimensional ICU liberation bundle which is a patient-oriented, holistic team approach to the management of critically ill patients aimed at reducing ICU distress and immediate and long-lasting consequences of PADIS.

HEPATIC DYSFUNCTION IN MEDICAL INTENSIVE CAREUNIT PATIENTS PREDICTS POOR OUTCOME.

BACKGROUND: A large number of patients admitted to the medical intensive care unit (MICU) have abnormal liver function tests (LFT). This includes patients with critical illness with or without preexisting liver disease and patients with acute primary liver injury. There are very few studies which have investigated the spectrum of liver disease, clinical profile and outcome in patients admitted to the MICU. OBJECTIVE: To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the MICU. To evaluate the utility of model for end-stage liver disease (MELD) score on admission as a predictor of adverse short term outcome in patients with hepatic dysfunction admitted in MICU. METHODS: It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with LFTs as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters. RESULTS: LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0%). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with chronic liver disease, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 56.4% (114/202). CONCLUSION: Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome.

Disfunção hepática em pacientes de unidade de terapia intensiva médica prevê desfecho desfavorável / Hepatic dysfunction in medical intensive careunit patients predicts poor outcome

ABSTRACT Background: A large number of patients admitted to the medical intensive care unit (MICU) have abnormal liver function tests (LFT). This includes patients with critical illness with or without preexisting liver disease and patients with acute primary liver injury. There are very few studies which have investigated the spectrum of liver disease, clinical profile and outcome in patients admitted to the MICU. Objective To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the MICU. To evaluate the utility of model for end-stage liver disease (MELD) score on admission as a predictor of adverse short term outcome in patients with hepatic dysfunction admitted in MICU. Methods: It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with LFTs as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters. Results: LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0%). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with chronic liver disease, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 56.4% (114/202). Conclusion: Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome.

RESUMO Contexto: Um grande número de pacientes internados na unidade de terapia intensiva (UTI) tem testes de função hepática anormais (TFH). Isso inclui pacientes com doença crítica com ou sem doença hepática pré-existente e pacientes com lesão hepática primária aguda. Há poucos estudos que têm investigado o espectro da doença hepática, perfil clínico e desfecho em pacientes admitidos em UTI. Objetivo Avaliar a ocorrência, etiologia, perfil clínico, perfil laboratorial e desfecho de disfunção hepática em pacientes internados na UTI médica. Avaliar a utilidade do modelo para doença hepática em estágio terminal (MELD). Escore na admissão como preditor de desfecho adverso a curto prazo em pacientes com disfunção hepática admitida em UTI. Métodos: Foi realizado um estudo observacional prospectivo, de dezembro de 2017 a dezembro de 2018 em um hospital de atenção terciária. Foram analisados 202 pacientes internados na UTI com TFH conforme os critérios de inclusão e seu desfecho a curto prazo de 7 dias foi estudado em relação a diversos parâmetros. Resultados: Anormalidades dos testes estiveram presentes em 202/1126 (17,9%) dos pacientes internados na UTI. Doença crítica associada à disfunção hepática foi encontrada em 172 (85,2%) pacientes, doença hepática crônica em 11 (5,4%) pacientes e hepatite viral aguda em 19 (9,4%) pacientes. O sintoma mais comum foi a febre (68,3%), seguido de vômito (48,0%) casos. Entre as anormalidades do TFH, transaminases elevadas, INR e escore MELD elevados na admissão correlacionaram-se com desfecho ruim de curto prazo. Exigência de inotrópicos e ventilação mecânica correlacionaram-se com desfecho de curto prazo ruim. A mortalidade não diferiu significativamente entre pacientes com doença hepática crônica, pacientes com hepatite viral aguda e pacientes com doença crítica associada à disfunção hepática. A disfunção hepática em UTI esteve associada a um desfecho ruim e à uma alta mortalidade a curto prazo de 114/202 (56,4%). Conclusão: A anormalidade da função hepática é comum em pacientes que são admitidos nas unidades de tratamento intensivo e sua presença é um indicador de desfecho de curto prazo ruim.

Assessment of Fluid Responsiveness by Changes in End Tidal Carbon Dioxide During Passive Leg Raising Test and Fluid Challenge.

PURPOSE: It is rationale to predict fluid responsiveness for optimum hemodynamic management. Passive Leg Raising (PLR) causes reversible increase in cardiac output (CO) and changes in end-tidal CO2& pressure (ETCO2 ) can be considered surrogate for CO variations. We aimed to assess the variations in EtCO2 with PLR and fluid challenge (FC) and also compared it with systolic arterial pressure (SAP), mean arterial pressure (MAP), heart rate (HR) and central venous pressure (CVP). METHODOLOGY: This Prospective study was conducted in the ICU of a tertiary care teaching public hospital. PLR was performed before FC in patients of circulatory failure on mechanical ventilation. ETCO2 and hemodynamics were monitored and compared and correlated after PLR and FC. ROC curve of parameters, based on their Area under the Curve (AUC) was compared. MS Excel, PSPP version 1.0.1 was used for analysis. RESULTS: Among hundred patients studied, 74 showed ETCO2 change≥ 2 mmHg (>5%) and were fluid responders. Increase in Etco2 after PLR at 1minute and FC at 30 minutes was statistically significant (p=2.73×10-73) so is SAP(p=4.02×10-75) and MAP(p=1.75×10-75). AUC of predictive performance of parameters showed change in ETCO2 (AUC ROC 0.985 [0.938 to 0.999]) had significantly outperformed CVP (AUCROC 0.822 [0.733-0.892]), SAP (AUCROC 0.793 [0.701-0.868]), MAP (AUCROC 0.810 [0.719-0.881]), HR (AUCROC 0.574 [0.471-0.673]).

Conclusion: Variations in ETCO2 >5% induced by PLR can predict fluid responsiveness and is a reliable, non-invasive, easy, quick, and reversible method. ETCO2 is better predictor than SAP, MAP, CVP, and HR during PLR and FC. We may recommend PLR-induced changes in ETCO2 to predict fluid responsiveness in mechanically ventilated patients.