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1.
J Clin Monit Comput ; 2020 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-32185615

RESUMO

Any measurement is always afflicted with some degree of uncertainty. A correct understanding of the different types of uncertainty, their naming, and their definition is of crucial importance for an appropriate use of measuring instruments. However, in perioperative and intensive care medicine, the metrological requirements for measuring instruments are poorly defined and often used spuriously. The correct use of metrological terms is also of crucial importance in validation studies. The European Union published a new directive on medical devices, mentioning that in the case of devices with a measuring function, the notified body is involved in all aspects relating to the conformity of the device with the metrological requirements. It is therefore the task of the scientific societies to establish the standards in their area of expertise. Adopting the same understandings and definitions among clinicians and scientists is obviously the first step. In this metrologic review (part 1), we list and explain the most important terms defined by the International Bureau of Weights and Measures regarding quantities and units, properties of measurements, devices for measurement, properties of measuring devices, and measurement standards, with specific examples from perioperative and intensive care medicine.

2.
J Clin Monit Comput ; 2020 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-32185616

RESUMO

A measurement is always afflicted with some degree of uncertainty. A correct understanding of the different types of uncertainty, their naming, and their definition is of crucial importance for an appropriate use of the measuring instruments. However, in perioperative and intensive care medicine, the metrological requirements for measuring instruments are poorly defined and often used spuriously. The correct use of metrological terms is also of crucial importance in validation studies. The European Union published a new directive on medical devices, mentioning that in the case of devices with a measuring function, the notified body is involved in all aspects relating to the conformity of the device with the metrological requirements. It is therefore the task of scientific societies to establish the standards in their area of expertise. After adopting the same understandings and definitions (part 1), the different procedures for the validation of major quality criteria of measuring devices must be consensually established. In this metrologic review (part 2), we review the terms and definitions of validation, some basic processes leading to the display of an indication from a physiologic signal, and procedures for the validation of measuring instrument properties, with specific focus on perioperative and intensive care medicine including appropriate examples.

3.
Crit Care ; 24(1): 97, 2020 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-32204721

RESUMO

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

4.
Nutrients ; 12(2)2020 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-32024268

RESUMO

Nutrition therapy in sepsis is challenging and differs from the standard feeding approach in critically ill patients. The dysregulated host response caused by infection induces progressive physiologic alterations, which may limit metabolic capacity by impairing mitochondrial function. Hence, early artificial nutrition should be ramped-up and emphasis laid on the post-acute phase of critical illness. Caloric dosing is ideally guided by indirect calorimetry, and endogenous energy production should be considered. Proteins should initially be delivered at low volume and progressively increased to 1.3 g/kg/day following shock symptoms wane. Both the enteral and parenteral route can be (simultaneously) used to cover caloric and protein targets. Regarding pharmaconutrition, a low dose glutamine seems appropriate in patients receiving parenteral nutrition. Supplementing arginine or selenium is not recommended. High-dose vitamin C administration may offer substantial benefit, but actual evidence is too limited for advocating its routine use in sepsis. Omega-3 polyunsaturated fatty acids to modulate metabolic processes can be safely used, but non-inferiority to other intravenous lipid emulsions remains unproven in septic patients. Nutrition stewardship, defined as the whole of interventions to optimize nutritional approach and treatment, should be pursued in all septic patients but may be difficult to accomplish within a context of profoundly altered cellular metabolic processes and organ dysfunction caused by time-bound excessive inflammation and/or immune suppression. This review aims to provide an overview and practical recommendations of all aspects of nutritional therapy in the setting of sepsis.

5.
Acta Anaesthesiol Scand ; 64(3): 410-416, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31828753

RESUMO

BACKGROUND: In patients with septic shock, mortality is high, and survivors experience long-term physical, mental and social impairments. The ongoing Conservative vs Liberal Approach to fluid therapy of Septic Shock in Intensive Care (CLASSIC) trial assesses the benefits and harms of a restrictive vs standard-care intravenous (IV) fluid therapy. The hypothesis is that IV fluid restriction improves patient-important long-term outcomes. AIM: To assess the predefined patient-important long-term outcomes in patients randomised into the CLASSIC trial. METHODS: In this pre-planned follow-up study of the CLASSIC trial, we will assess all-cause mortality, health-related quality of life (HRQoL) and cognitive function 1 year after randomisation in the two intervention groups. The 1-year mortality will be collected from electronic patient records or central national registries in most participating countries. We will contact survivors and assess EuroQol 5-Dimension, -5-Level (EQ-5D-5L) and EuroQol-Visual Analogue Scale and Montreal Cognitive Assessment 5-minute protocol score. We will analyse mortality by logistic regression and use general linear models to assess HRQoL and cognitive function. DISCUSSION: With this pre-planned follow-up study of the CLASSIC trial, we will provide patient-important data on long-term survival, HRQoL and cognitive function of restrictive vs standard-care IV fluid therapy in patients with septic shock.

6.
Anaesth Crit Care Pain Med ; 39(1): 75-85, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31170485

RESUMO

BACKGROUND: Continuous non-invasive cardiac output devices using digital photoplethysmography (PPG) are widely available for bedside use, but their interchangeability with reference methods has not yet been evaluated in a systematic review and patient data meta-analysis. METHODS: A systematic review and meta-analysis of studies comparing non-invasive cardiac output monitoring using PPG with the invasive bolus thermodilution method was performed. With ethical approval, all published studies from the PUBMED, Embase, Scopus, Web of Science, and Google Scholar databases from January 1, 2010 to January 1, 2018 were included. From these analysed studies, individual patient data were interpreted using the interchangeability methods for both absolute values and changes in cardiac output measurements. RESULTS: Ten studies comparing PPG and bolus thermodilution in the operating room and intensive care settings were included. The interchangeability rate (95% CI) was 37% (24-48) (n=1350 pairs of measurements). The interchangeability rate was poorer with the CNAP device (CNSystems, Graz, Austria) [18% (17-20)] than with the Clearsight (Edwards Lifesciences, Irvine, CA) device [33% (31-34), P<0.0001], for patients receiving norepinephrine [19% (17-20) vs. 33% (32-34), P<0.0001], and for patients with low mean arterial pressure (<65mmHg) [26% (23-29) vs. 30% (29-31), P<0.0001]. Among the 1009 comparisons of the changes in cardiac output between both methods, 561 (56%) were interpretable with a trend interchangeability rate at 24% (12-36). CONCLUSIONS: Cardiac output measurements using PPG were not interchangeable with bolus thermodilution in regard to both absolute values and changes in cardiac output measurements, and should be used with caution in clinical practice. TRIAL REGISTRATION: PROSPERO ID CRD42018089513.

8.
Curr Opin Crit Care ; 25(6): 605-612, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31567518

RESUMO

PURPOSE OF REVIEW: Critical care echocardiography (CCE) has become an important component of general critical care ultrasonography, and a current review of its performance is presented. RECENT FINDINGS: Basic CCE should be performed as a goal-directed examination to better identify specific signs and to answer important clinical questions concerning acute hemodynamic concerns. It has evolved in the ICU and also in the emergency department not only for improved diagnostic capability but also as an effective part of the triage process. It remains an efficacious procedure even in patients with respiratory failure when combined with lung ultrasonography. Numerous acronyms were proposed, but in all cases, CCE responds to the same rules as fundamental echocardiography. Basic CCE requires accessible and comprehensive training for physicians and is mandatory for all intensivists. Development of pocket echo devices may increase the use of basic CCE as has miniaturization of other medical technologies. Performance should be managed by guidelines, and the CCE training program should be standardized worldwide. More trials are welcome to evaluate its impact on patient outcomes. SUMMARY: Thanks to its ability to quickly obtain a diagnostic orientation at the bedside and to implement targeted therapy, basic CCE over the past decade has become an essential tool for hemodynamic assessment of the cardiopulmonary unstable patient. Its more recent incorporation into the education of trainees in medical school and residencies/fellowships has reinforced its perceived importance in critical care management, despite the relative paucity as yet of rigorous scientific evidence demonstrating positive outcome modification from its use.

9.
Curr Opin Crit Care ; 25(6): 613-621, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31574015

RESUMO

PURPOSE OF REVIEW: The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed. RECENT FINDINGS: Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited. The list of indications for POCUS nonetheless is increasing as practitioners acknowledge clinical benefits, and technological advancement improves diagnostic accuracy and efficiency of use. SUMMARY: We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario.

10.
Intensive Care Med ; 45(10): 1422-1432, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31576437

RESUMO

PURPOSE: To determine the effects of the sodium content of maintenance fluid therapy on cumulative fluid balance and electrolyte disorders. METHODS: We performed a randomized controlled trial of adults undergoing major thoracic surgery, randomly assigned (1:1) to receive maintenance fluids containing 154 mmol/L (Na154) or 54 mmol/L (Na54) of sodium from the start of surgery until their discharge from the ICU, the occurrence of a serious adverse event or the third postoperative day at the latest. Investigators, caregivers and patients were blinded to the treatment. Primary outcome was cumulative fluid balance. Electrolyte disturbances were assessed as secondary endpoints, different adverse events and physiological markers as safety and exploratory endpoints. FINDINGS: We randomly assigned 70 patients; primary outcome data were available for 33 and 34 patients in the Na54 and Na154 treatment arms, respectively. Estimated cumulative fluid balance at 72 h was 1369 mL (95% CI 601-2137) more positive in the Na154 arm (p < 0.001), despite comparable non-study fluid sources. Hyponatremia < 135 mmol/L was encountered in four patients (11.8%) under Na54 compared to none under Na154 (p = 0.04), but there was no significantly more hyponatremia < 130 mmol/L (1 versus 0; p = 0.31). There was more hyperchloremia > 109 mmol/L under Na154 (24/35 patients, 68.6%) than under Na54 (4/34 patients, 11.8%) (p < 0.001). The treating clinicians discontinued the study due to clinical or radiographic fluid overload in six patients receiving Na154 compared to one patient under Na54 (excess risk 14.2%; 95% CI - 0.2-30.4%, p = 0.05). CONCLUSIONS: In adult surgical patients, sodium-rich maintenance solutions were associated with a more positive cumulative fluid balance and hyperchloremia; hypotonic fluids were associated with mild and asymptomatic hyponatremia.

13.
Acta Anaesthesiol Scand ; 63(9): 1262-1271, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31276193

RESUMO

INTRODUCTION: Intravenous (IV) fluid is a key intervention in the management of septic shock. The benefits and harms of lower versus higher fluid volumes are unknown and thus clinical equipoise exists. We describe the protocol and detailed statistical analysis plan for the conservative versus liberal approach to fluid therapy of septic shock in the Intensive Care (CLASSIC) trial. The aim of the CLASSIC trial is to assess benefits and harms of IV fluid restriction versus standard care in adult intensive care unit (ICU) patients with septic shock. METHODS: CLASSIC trial is an investigator-initiated, international, randomised, stratified, and analyst-blinded trial. We will allocate 1554 adult patients with septic shock, who are planned to be or are admitted to an ICU, to IV fluid restriction versus standard care. The primary outcome is mortality at day 90. Secondary outcomes are serious adverse events (SAEs), serious adverse reactions (SARs), days alive at day 90 without life support, days alive and out of the hospital at day 90 and mortality, health-related quality of life (HRQoL), and cognitive function at 1 year. We will conduct the statistical analyses according to a pre-defined statistical analysis plan, including three interim analyses. For the primary analysis, we will use logistic regression adjusted for the stratification variables comparing the two interventions in the intention-to-treat (ITT) population. DISCUSSION: The CLASSIC trial results will provide important evidence to guide clinicians' choice regarding the IV fluid therapy in adults with septic shock.

14.
Crit Care ; 23(1): 219, 2019 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-31200780

RESUMO

BACKGROUND: The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe. METHODS: A multinational, multicenter, retrospective study was conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU). RESULTS: During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio [OR] 1.04 per year, 95% CI 1.02-1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31-8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04-1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24-3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis. CONCLUSIONS: The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.


Assuntos
Candidíase Invasiva/complicações , Idoso , Candidíase Invasiva/epidemiologia , Infecção Hospitalar/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , /normas , Estudos Retrospectivos , Fatores de Risco
15.
Ann Intensive Care ; 9(1): 56, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31089920

RESUMO

Although improving, the mortality from septic shock still remains high despite increased international awareness. As a consequence, much effort has focused on alternative treatment strategies in an effort to improve outcomes. The application of blood purification therapies to improve immune homeostasis has been suggested as one such method, but these approaches, such as high-volume continuous haemofiltration or cytokine and/or endotoxin removal, have enjoyed little success to date. More recently, the use of sorbent technologies has attracted much attention. These adsorbers are highly effective at removing inflammatory mediators, in particular, cytokines, from the bloodstream. This narrative review is the executive summary of meetings held throughout the 6th International Fluid Academy Days in Antwerp, Belgium (Nov 23-25, 2017), focusing on the current understanding regarding the use of such adsorbers in humans with septic shock. We followed a modified Delphi approach involving a combination of evidence appraisal together with expert opinion in order to achieve recommendations for practice and, importantly, future research.

16.
Acta Obstet Gynecol Scand ; 98(11): 1386-1397, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31070780

RESUMO

Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.

17.
Ann Intensive Care ; 9(1): 52, 2019 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-31025221

RESUMO

The incidence of intra-abdominal hypertension (IAH) is high and still underappreciated by critical care physicians throughout the world. One in four to one in three patients will have IAH on admission, while one out of two will develop IAH within the first week of Intensive Care Unit stay. IAH is associated with high morbidity and mortality. Although considerable progress has been made over the past decades, some important questions remain regarding the optimal ventilation management in patients with IAH. An important first step is to measure intra-abdominal pressure (IAP). If IAH (IAP > 12 mmHg) is present, medical therapies should be initiated to reduce IAP as small reductions in intra-abdominal volume can significantly reduce IAP and airway pressures. Protective lung ventilation with low tidal volumes in patients with respiratory failure and IAH is important. Abdominal-thoracic pressure transmission is around 50%. In patients with IAH, higher positive end-expiratory pressure (PEEP) levels are often required to avoid alveolar collapse but the optimal PEEP in these patients is still unknown. During recruitment manoeuvres, higher opening pressures may be required while closely monitoring oxygenation and the haemodynamic response. During lung-protective ventilation, whilst keeping driving pressures within safe limits, higher plateau pressures than normally considered might be acceptable. Monitoring of the respiratory function and adapting the ventilatory settings during anaesthesia and critical care are of great importance. This review will focus on how to deal with the respiratory derangements in critically ill patients with IAH.

19.
Acta Neurochir (Wien) ; 161(5): 855-864, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30911831

RESUMO

Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders.

20.
Curr Opin Crit Care ; 25(2): 150-156, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30730344

RESUMO

PURPOSE OF REVIEW: To review recent literature on the management of patients with severe acute pancreatitis (SAP) admitted to an ICU. RECENT FINDINGS: SAP is a devastating disease associated with a high morbidity and mortality. Recent evidence advocates adequate risk assessment and severity prediction (including intra-abdominal pressure monitoring), tailored fluid administration favoring balanced crystalloids, withholding prophylactic antibiotic therapy, and early detection and treatment of extra-pancreatic and fungal infections. Urgent (within 24-48 h after diagnosis) endoscopic retrograde cholangiopancreatography is indicated when persistent biliary obstruction or cholangitis are present. Corticosteroid therapy (mainly dexamethasone) can reduce the need for surgical interventions, length of hospital stay, and mortality. Peritoneal lavage may significantly lower morbidity and mortality. Hemofiltration may offer substantial benefit but more studies are needed to prove its efficacy. Enteral feeding using a polymeric formula and provided early through a nasogastric tube is recommended but has no survival benefit compared with parenteral nutrition. Probiotics could be beneficial, however no clear recommendations can be made. SUMMARY: Management of SAP is multimodal with emphasis on monitoring, adequate fluid resuscitation, avoiding prophylactic use of antibiotics, cause-directed procedures or treatment, and organ support. There is a role for early enteral nutrition including probiotics.

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