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The latest research articles published by Critical Care
Actualizado: hace 2 años 12 semanas

Nutrition support practices in critically ill head-injured patients: a global perspective

Jue, 07/01/2016 - 02:00
Background: Critical illness following head injury is associated with a hypermetabolic state but there are insufficient epidemiological data describing acute nutrition delivery to this group of patients. Furthermore, there is little information describing relationships between nutrition and clinical outcomes in this population. Methods: We undertook an analysis of observational data, collected prospectively as part of International Nutrition Surveys 2007-2013, and extracted data obtained from critically ill patients with head trauma. Our objective was to describe global nutrition support practices in the first 12 days of hospital admission after head trauma, and to explore relationships between energy and protein intake and clinical outcomes. Data are presented as mean (SD), median (IQR), or percentages. Results: Data for 1045 patients from 341 ICUs were analyzed. The age of patients was 44.5 (19.7) years, 78 % were male, and median ICU length of stay was 13.1 (IQR 7.9-21.6) days. Most patients (94 %) were enterally fed but received only 58 % of estimated energy and 53 % of estimated protein requirements. Patients from an ICU with a feeding protocol had greater energy and protein intakes (p?<0.001, 0.002 respectively) and were more likely to survive (OR 0.65; 95 % CI 0.42-0.99; p?=?0.043) than those without. Energy or protein intakes were not associated with mortality. However, a greater energy and protein deficit was associated with longer times until discharge alive from both ICU and hospital (all p?<0.001). Conclusion: Nutritional deficits are commonplace in critically ill head-injured patients and these deficits are associated with a delay to discharge alive.

Safety and efficacy of prothrombin complex concentrate as first-line treatment in bleeding after cardiac surgery

Mié, 06/01/2016 - 02:00
Background: Bleeding after cardiac surgery requiring surgical reexploration and blood component transfusion is associated with increased morbidity and mortality. Although prothrombin complex concentrate (PCC) has been used satisfactorily in bleeding disorders, studies on its efficacy and safety after cardiopulmonary bypass are limited. Methods: Between January 2005 and December 2013, 3454 consecutive cardiac surgery patients were included in an observational study aimed at investigating the efficacy and safety of PCC as first-line coagulopathy treatment as a replacement for fresh frozen plasma (FFP). Starting in January 2012, PCC was introduced as solely first-line treatment for bleeding following cardiac surgery. Results: After one-to-one propensity score–matched analysis, 225 pairs of patients receiving PCC (median dose 1500 IU) and FFP (median dose 2 U) were included. The use of PCC was associated with significantly decreased 24-h post-operative blood loss (836?±?1226 vs. 935?±?583 ml, p?<?0.0001). Propensity score–adjusted multivariate analysis showed that PCC was associated with significantly lower risk of red blood cell (RBC) transfusions (odds ratio [OR] 0.50; 95 % confidence interval [CI] 0.31–0.80), decreased amount of RBC units (? unstandardised coefficient ?1.42, 95 % CI ?2.06 to ?0.77) and decreased risk of transfusion of more than 2 RBC units (OR 0.53, 95 % CI 0.38–0.73). Patients receiving PCC had an increased risk of post-operative acute kidney injury (AKI) (OR 1.44, 95 % CI 1.02–2.05) and renal replacement therapy (OR 3.35, 95 % CI 1.13–9.90). Hospital mortality was unaffected by PCC (OR 1.51, 95 % CI 0.84–2.72). Conclusions: In the cardiac surgery setting, the use of PCC compared with FFP was associated with decreased post-operative blood loss and RBC transfusion requirements. However, PCC administration may be associated with a higher risk of post-operative AKI.

Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA <it>versus</it> PSV

Mar, 05/01/2016 - 02:00
Background: Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency.MethodPatients previously ventilated with controlled mechanical ventilation for 72 hours or more were randomized to be ventilated for 48 hours with pressure support ventilation (n =12) or neurally adjusted ventilatory assist (n?=?13). Neuro-ventilatory efficiency (tidal volume/diaphragmatic electrical activity) and neuro-mechanical efficiency (pressure generated against the occluded airways/diaphragmatic electrical activity) were measured during three spontaneous breathing trials (0, 24 and 48 hours). Breathing pattern, diaphragmatic electrical activity and pressure time product of the diaphragm were assessed every 4 hours. Results: In patients randomized to neurally adjusted ventilator assist, neuro-ventilatory efficiency increased from 27?±?19 ml/?V at baseline to 62?±?30 ml/?V at 48 hours (p?<0.0001) and neuro-mechanical efficiency increased from 1?±?0.6 to 2.6?±?1.1 cmH 2 O/?V (p?=?0.033). In patients randomized to pressure support ventilation, these did not change. Electrical activity of the diaphragm, neural inspiratory time, pressure time product of the diaphragm and variability of the breathing pattern were significantly higher in patients ventilated with neurally adjusted ventilatory assist. The asynchrony index was 9.48 [6.38– 21.73] in patients ventilated with pressure support ventilation and 5.39 [3.78– 8.36] in patients ventilated with neurally adjusted ventilatory assist (p?=?0.04). Conclusion: After prolonged controlled mechanical ventilation, neurally adjusted ventilator assist improves diaphragm efficiency whereas pressure support ventilation does not.Trial registrationClinicalTrials.gov study registration: NCT0247317, 06/11/2015.

Molecular adsorbent recirculating system and single-pass albumin dialysis in liver failure &#8211; a prospective, randomised crossover study

Lun, 04/01/2016 - 14:00
Background: The aim of extracorporeal albumin dialysis (ECAD) is to reduce endogenous toxins accumulating in liver failure. To date, ECAD is conducted mainly with the Molecular Adsorbents Recirculating System (MARS). However, single-pass albumin dialysis (SPAD) has been proposed as an alternative. The aim of this study was to compare the two devices with a prospective, single-centre, non-inferiority crossover study design with particular focus on reduction of bilirubin levels (primary endpoint) and influence on paraclinical and clinical parameters (secondary endpoints) associated with liver failure. Methods: Patients presenting with liver failure were screened for eligibility and after inclusion were randomly assigned to be started on either conventional MARS or SPAD (with 4 % albumin and a dialysis flow rate of 700 ml/h). Statistical analyses were based on a linear mixed-effects model. Results: Sixty-nine crossover cycles of ECAD in 32 patients were completed. Both systems significantly reduced plasma bilirubin levels to a similar extent (MARS: median ?68 ?mol/L, interquartile range [IQR] ?107.5 to ?33.5, p?=?0.001; SPAD: ?59 ?mol/L, ?84.5 to +36.5, p?=?0.001). However, bile acids (MARS: ?39 ?mol/L, ?105.6 to ?8.3, p?<?0.001; SPAD: ?9 ?mol/L, ?36.9 to +11.4, p?=?0.131), creatinine (MARS: ?24 ?mol/L, ?46.5 to ?8.0, p?<?0.001; SPAD: ?2 ?mol/L, ?9.0 to +7.0/L, p?=?0.314) and urea (MARS: ?0.9 mmol/L, ?1.93 to ?0.10, p?=?0.024; SPAD: ?0.1 mmol/L, ?1.0 to +0.68, p?=?0.523) were reduced and albumin-binding capacity was increased (MARS: +10 %, ?0.8 to +20.9 %, p?<?0.001; SPAD: +7 %, ?7.5 to +15.5 %, p?=?0.137) only by MARS. Cytokine levels of interleukin (IL)-6 and IL-8 and hepatic encephalopathy were altered by neither MARS nor SPAD. Conclusions: Both procedures were safe for temporary extracorporeal liver support. While in clinical practice routinely assessed plasma bilirubin levels were reduced by both systems, only MARS affected other paraclinical parameters (i.e., serum bile acids, albumin-binding capacity, and creatinine and urea levels). Caution should be taken with regard to metabolic derangements and electrolyte disturbances, particularly in SPAD using regional citrate anti-coagulation.Trial registrationGerman Clinical Trials Register (www.drks.de) DRKS00000371. Registered 8 April 2010.

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