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Arginine immunonutrition in critically ill patients: a clinical dilemma.
Stechmiller JK, Childress B, Porter T.
Adult and Elderly Department, University of Florida College of Nursing, Gainesville, Fla., USA.
Commercial enteral nutritional formulas for enhancement of the immune system are widely used in critical care. Immunonutrition with arginine can enhance inflammatory and immunologic responses in animal models and in humans. Although clinical improvements in surgical patients have been reported, benefits in critically ill patients with systemic inflammatory response syndrome, sepsis, or organ failure are less clear. Recent meta-analyses on the use of immunonutrition with arginine in critically ill and surgical patients revealed methodological weaknesses in most published studies. Specifically, a meta-analysis indicated that critically ill patients with preexisting severe sepsis may have an increased mortality rate when fed an immunonutritional enteral formula that contains arginine. These findings brought about confusion and controversy over the use of immunonutritional formulas in subsets of critically ill patients. A review of the literature on the function of arginine, its effect on the immune system, its roles in immunonutrition and in the clinical outcomes of critically ill patients, and the implications for nursing practice indicated that the benefits of immunonutrition with arginine in critically ill patients are unproven and warrant further study. Until more information is available, nutritional support should focus primarily on preventing nutritional deficiencies rather than on immunomodulation.
Publication Types:
PMID: 14735643 [PubMed - indexed for MEDLINE]
Comment in:
A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation.
Krishnan JA, Moore D, Robeson C, Rand CS, Fessler HE.
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
Weaning protocols can improve outcomes, but their efficacy may vary with patient and staff characteristics. In this prospective, controlled trial, we compared protocol-based weaning to usual, physician-directed weaning in a closed medical intensive care unit (ICU) with high physician staffing levels and structured, system-based rounds. Adult patients requiring mechanical ventilation for more than 24 hours were assigned to usual care (UC) or protocol weaning based on their hospital identification number. Patients assigned to UC (n=145) were managed at their physicians' discretion. Patients assigned to protocol (n=154) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention. There were no significant baseline differences in patient characteristics between groups. The proportion of patients (protocol vs. UC) who successfully discontinued mechanical ventilation (74.7% vs. 75.2%, p=0.92), duration of mechanical ventilation (median [interquartile range]: 60.4 hours [28.6-167.0 hours] vs. 68.0 hours [27.1-169.3 hours], p=0.61), ICU (25.3% vs. 28.3%) and hospital mortality (36.4% vs. 33.1%), ICU length of stay (115 vs. 146 hours), and rates of reinstituting mechanical ventilation (10.3% vs. 9.0%) was similar. We conclude that protocol-directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 14726421 [PubMed - indexed for MEDLINE]
Pharmacokinetics of remifentanil and its major metabolite, remifentanil acid, in ICU patients with renal impairment.
Pitsiu M, Wilmer A, Bodenham A, Breen D, Bach V, Bonde J, Kessler P, Albrecht S, Fisher G, Kirkham A.
Medeval Ltd, Skelton House, Manchester Science Park, Lloyd Street North, Manchester M15 6SH, UK. m.pitsiu@medeval.com
BACKGROUND: The pharmacokinetics of remifentanil, an opioid analgesic metabolized by non-specific esterases, and its principal metabolite, remifentanil acid (RA), which is excreted via the kidneys, were assessed as part of an open-label safety study in intensive care unit (ICU) patients with varying degrees of renal impairment. METHODS: Forty adult ICU patients with normal/mildly impaired renal function (creatinine clearance [CL(cr)] 62.9 (sd) 14.5 ml min(-1); n=10) or moderate/severe renal impairment (CL(cr) 14.7 (15.7) ml min(-1); n=30) were included. Remifentanil was infused for up to 72 h, at a starting rate of 6-9 microg kg(-1) h(-1) titrated to achieve a target sedation level, with additional propofol (0.5 mg kg(-1) h(-1)) if required. Intensive arterial sampling was performed for up to 72 h after infusion. Pharmacokinetic parameters obtained by simultaneous modelling of remifentanil and RA data were statistically compared between the two groups. RESULTS: Remifentanil pharmacokinetics were not significantly affected by renal status. RA clearance in the moderate/severe group was reduced to about 25% that of the normal/mild group (41 (29) vs 176 (49) ml kg(-1) h(-1), P<0.0001). Metabolic ratio, a predictor of the ratio of RA to remifentanil concentrations at steady state, was approximately eight-fold higher in the moderate/severe group relative to the normal/mild group (116 (110) vs 15 (4), P<0.0001). Maximum RA levels approached 700 ng ml(-1) in the moderate/severe group. CONCLUSIONS: Although RA accumulates in patients with moderate/severe renal impairment, pharmacokinetic modelling predicts that RA concentrations during a 9 microg kg(-1) h(-1) remifentanil infusion for up to 15 days would not exceed those reported in the present study, for which no associated prolongation of mu-opioid effects was observed.
Publication Types:
- Clinical Trial
- Controlled Clinical Trial
PMID: 14766712 [PubMed - indexed for MEDLINE]
Prediction of risk of death using 30-day outcome: a practical end point for quality auditing in intensive care.
Graham PL, Cook DA.
School of Mathematical and Physical Sciences, University of Newcastle, Callaghan, NSW, Australia. pgraham@maths.newcastle.edu.au
STUDY OBJECTIVE: To validate the APACHE (acute physiology and chronic health evaluation) III unadjusted and similar hospital mortality estimate models on 30-day mortality, and to propose a simple approach to modeling local 30-day in-hospital mortality of critically ill hospitalized adults for quality management and risk-adjusted monitoring. DESIGN: Noninterventional, observational study. PATIENTS: A total of 5,278 consecutive eligible hospital admissions between January 1, 1995, and December 31, 1999. MEASUREMENTS: Prospective collection of demographic, diagnostic, physiologic, laboratory, and hospital admission and discharge data. RESULTS: The APACHE III mortality predictions exhibited excellent discrimination (receiver operating characteristic [ROC] curve area) for 30-day outcome (ROC area, 0.89) and hospital outcome (ROC area, 0.89). Calibration curves and Hosmer-Lemeshow statistics demonstrated good calibration of all models on 30-day outcome, except for the unadjusted APACHE III model. New, simplified risk adjustment models showed good discrimination and calibration on development and test data. ROC areas were 0.88 (developmental data) and 0.87 (test data), and the new model calibration was equivalent to the APACHE III model. CONCLUSION: For quality audit, 30-day in-hospital mortality can be used as an alternative outcome to survival to hospital discharge. New logistic regression models provide evidence that local models, possessing good calibration and discrimination, may be built from a few explanatory variables.
PMID: 15078759 [PubMed - in process]
Comment on:
Comparison of effectiveness of two urinary drainage systems in intensive care unit: a prospective, randomized clinical trial.
[No authors listed]
Publication Types:
PMID: 15085791 [PubMed - indexed for MEDLINE]
Quality of life after complicated elective surgery requiring intensive care.
Lamer C, Harboun M, Knani L, Moreau D, Tric L, LeGuillou JL, Gasquet I, Moreau T.
Departement de Reanimation Polyvalente, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75674, Paris, France.
OBJECTIVE. To evaluate outcomes of patients admitted to the ICU for complications after elective surgery and to assess perceived quality of life (pQOL) in survivors. DESIGN. Two-year prospective case-control study. SETTING. Twelve-bed ICU in a university-affiliated hospital. PATIENTS. Patients admitted to the ICU for a complication following elective surgery were included. Six months after discharge, pQOL was assessed using the Nottingham Health Profile (NHP). Results were compared to those of matched controls without complications. INTERVENTIONS. None MEASUREMENTS AND RESULTS. Of the 182 patients, 124 were alive after 6 months, among whom 116 had 6-month data and 104 of these had matched controls. Overall pQOL as assessed by the global NHP score was similar in both groups (median, 0.82 and 0.87 in cases and controls; P=0.24). NHP subscores showed significantly worse pain ( P=0.03) and physical impairment ( P=0.02) in the ICU patients. In the multivariate analysis, pQOL was better in patients with cancer as the reason for surgery ( P=0.05). Severity of illness at inclusion had no influence on subsequent pQOL, but cardiovascular dysfunction was associated with decreased energy ( P=0.04). CONCLUSIONS. Although overall pQOL was satisfactory after 6 months, patients admitted to the ICU for postoperative complications had worse pain and physical impairment than controls. Whether these outcomes could be improved by early physiotherapy and aggressive pain management deserves investigation.
PMID: 15085322 [PubMed - as supplied by publisher]
Comment on:
Risk factors of nosocomial catheter-associated urinary tract infection in a polyvalent intensive care unit.
[No authors listed]
Publication Types:
PMID: 15080149 [PubMed - indexed for MEDLINE]
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Evaluation and management of decompression illness--an intensivist's perspective.
Tetzlaff K, Shank ES, Muth CM.
1st Department of Medicine, Christian-Albrechts-University of Kiel, Schittenhelmstrasse 12, 24105, Kiel, Germany. Kay.Tetzlaff@bc.boehringer-ingelheim.com
Decompression illness (DCI) is becoming more prevalent as more people engage in activities involving extreme pressure environments such as recreational scuba-diving. Rapid diagnosis and treatment offer these patients the best chance of survival with minimal sequelae. It is thus important that critical care physicians are able to evaluate and diagnose the signs and symptoms of DCI. The cornerstones of current treatment include the administration of hyperbaric oxygen and adjunctive therapies such as hydration and medications. However, managing patients in a hyperbaric environment does present additional challenges with respect to the particular demands of critical care medicine in an altered pressure environment. This article reviews the underlying pathophysiology, clinical presentation and therapeutic options available to treat DCI, from the intensivist's perspective.
Publication Types:
PMID: 14600806 [PubMed - indexed for MEDLINE]
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Validation of the multiple organ dysfunction (MOD) score in critically ill medical and surgical patients.
Buckley TA, Gomersall CD, Ramsay SJ.
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, NT, Shatin, Hong Kong.
OBJECTIVE: To validate the Multiple Organ Dysfunction (MOD) score externally. DESIGN: Prospective observational cohort study. SETTING: Mixed medical/surgical ICU in a tertiary referral university hospital. PATIENTS AND PARTICIPANTS: Thousand eight hundred and nine patients admitted to ICU for more than 24 h over a 3-year period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The MOD score was calculated daily for all patients. The criterion validity of the individual organ scores, the maximal MOD score and the change in MOD score were assessed by examining the relationship between increasing scores and ICU mortality. Increased maximal MOD scores and each of the six individual organ scores, and change in MOD scores were associated with increased mortality. CONCLUSIONS: Maximal and individual organ scores have criterion validity when tested in a different ICU from that in which the scores were derived, indicating that the scoring systems are reproducible. The association of change in MOD score with mortality indicates that the score is responsive. These data, combined with previous data establishing concept and content validity, indicate that the MOD score is a valid measure of multi-organ dysfunction.
PMID: 14566459 [PubMed - indexed for MEDLINE]
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HDL-cholesterol level and cortisol response to synacthen in critically ill patients.
van der Voort PH, Gerritsen RT, Bakker AJ, Boerma EC, Kuiper MA, de Heide L.
Department of Intensive Care, Medical Centre Leeuwarden, PO Box 888, 8901 BR, Leeuwarden, The Netherlands. phjvdvoort@wxs.nl
OBJECTIVE: To explore the relationship between cholesterol levels and the adrenal cortisol response to synacthen in critically ill patients. DESIGN: Prospective observational study. PATIENTS: Critically ill patients with multiple organ dysfunction syndrome (MODS) with possible adrenal dysfunction defined as unexplained hypotension, ongoing inotropic support, unexplained fever, unexplained hyponatraemia or a combination of these symptoms. MEASUREMENTS: HDL-cholesterol levels (HDL), total cholesterol levels (TC), and triglycerides (TG) before administration of synacthen. LDL-cholesterol was calculated using the Friedewald formula. Basal cortisol and response to 250 microg synacthen intravenously was measured. A cortisol rise of 0.25 micromol/l in a 30-min or 60-min blood sample after synacthen infusion was defined as a proper adrenal response. RESULTS: Patients with a proper response to synacthen showed higher HDL-cholesterol levels than patients without that response ( P=0.02). Severity of disease as measured by APACHE II or SOFA was not a confounder. LDL-cholesterol levels were extremely low in both responders and non-responders and were not associated with the absolute rise in cortisol. In linear and logistic regression analysis HDL-cholesterol was the sole predictor of cortisol response. CONCLUSIONS: Adrenal cortisol response to a "classic" 250-microg synacthen test relates in critically ill patients to HDL-cholesterol levels. LDL and TC levels did not show such a relation. These findings are in concordance with known biochemical pathways of cortisol production.
Publication Types:
PMID: 14566456 [PubMed - indexed for MEDLINE]
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Using hierarchical modeling to measure ICU quality.
Glance LG, Dick AW, Osler TM, Mukamel D.
University of Rochester, School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA. Laurent_Glance@urmc.rochester.edu
OBJECTIVE: To determine whether hierarchical modeling agrees with conventional logistic regression modeling on the identity of ICU quality outliers within a large multi-institutional database. DESIGN: Retrospective database analysis. SETTING AND PATIENTS: Subset of the Project IMPACT database consisting of 40435 adult patients admitted to surgical, medical, and mixed surgical-medical ICUs ( n=55) between 1997 and 1999 who met inclusion criteria for SAPS II. MEASUREMENTS AND RESULTS: The SAPS II score was customized to this database using conventional logistic regression and using a hierarchical (random coefficients) model. Both models exhibited excellent discrimination ( Cstatistic) and calibration (Hosmer-Lemeshow statistic). The hierarchical and nonhierarchical models had C statistics of.870 and.865, and HL statistics of 3.71 ( p>.88, df=8) and 8.94 ( p>.35, df=8), respectively. Since the random effects component of the hierarchical model accounts for between-hospital variability, only the fixed-effects coefficients were used to calculate the expected mortality rate based on the hierarchical model. The ratio and 95% confidence intervals of the observed to expected mortality rate were calculated using both models for each ICU. ICUs whose observed/expected ratio was either less than 1 or greater than 1, and whose 95% confidence interval did not include 1 were labeled as either high-performance or low-performance outliers, respectively. Analysis using kappa statistic revealed almost perfect agreement between the two models (nonhierarchical vs. hierarchical) on the identity of ICU quality outliers. CONCLUSIONS: Models obtained by customizing SAPS II using a nonhierarchical and a hierarchical approach exhibit excellent agreement on the identity of ICU quality outliers.
PMID: 14534777 [PubMed - indexed for MEDLINE]
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Candidemia in critically ill patients: difference of outcome between medical and surgical patients.
Charles PE, Doise JM, Quenot JP, Aube H, Dalle F, Chavanet P, Milesi N, Aho LS, Portier H, Blettery B.
Service de Reanimation Medicale, Dijon University Hospital, BP 1519, 21033, Dijon, France. pierre-emmanuel.charles@chu-dijon.fr
OBJECTIVE: Candidemia is increasingly encountered in critically ill patients with a high fatality rate. The available data in the critically ill suggest that patients with prior surgery are at a higher risk than others. However, little is known about candidemia in medical settings. The main goal of this study was to compare features of candidemia in critically ill medical and surgical patients. DESIGN: Ten-year retrospective cohort study (1990-2000). SETTING: Medical and surgical intensive care units (ICUs) of a teaching hospital. PATIENTS: Fifty-one patients with at least one positive blood culture for Candida species. MAIN RESULTS: Risk factors were retrieved in all of the patients: central venous catheter (92.1%), mechanical ventilation (72.5%), prior bacterial infection (70.6%), high fungal colonization index (45.6%). Candida albicans accounts for 55% of all candidemia. The overall mortality was 60.8% (85% and 45.2% in medical and surgical patients, respectively). Independent factors associated with survival were prior surgery (hazard ratio [HR] =0.25; 0.09-0.67 95% confidence interval [CI], p<0.05), antifungal treatment (HR =0.11; 0.04-0.30 95% CI, p<0.05) and absence of neutropenia (HR =0.10; 0.02-0.45 95% CI, p<0.05). Steroids, neutropenia and high density of fungal colonization were more frequently found among medical patients compared to surgical ones. CONCLUSIONS: Candidemia occurrence is associated with a high mortality rate among critically ill patients. Differences in underlying conditions could account for the poorer outcome of the medical patients. Screening for fungal colonization could allow identification of such high-risk patients and, in turn, improve outcome.
PMID: 13680110 [PubMed - indexed for MEDLINE]
Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit.
Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS.
Department of Medicine, Division of General Internal Medicine and Center for Health Services Research and the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center, Nashville, Tenn, USA.
CONTEXT: In the intensive care unit (ICU), delirium is a common yet underdiagnosed form of organ dysfunction, and its contribution to patient outcomes is unclear. OBJECTIVE: To determine if delirium is an independent predictor of clinical outcomes, including 6-month mortality and length of stay among ICU patients receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study enrolling 275 consecutive mechanically ventilated patients admitted to adult medical and coronary ICUs of a US university-based medical center between February 2000 and May 2001. Patients were followed up for development of delirium over 2158 ICU days using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale. MAIN OUTCOME MEASURES: Primary outcomes included 6-month mortality, overall hospital length of stay, and length of stay in the post-ICU period. Secondary outcomes were ventilator-free days and cognitive impairment at hospital discharge. RESULTS: Of 275 patients, 51 (18.5%) had persistent coma and died in the hospital. Among the remaining 224 patients, 183 (81.7%) developed delirium at some point during the ICU stay. Baseline demographics including age, comorbidity scores, dementia scores, activities of daily living, severity of illness, and admission diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month mortality rates (34% vs 15%, P =.03) and spent 10 days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age, severity of illness, comorbid conditions, coma, and use of sedatives or analgesic medications), delirium was independently associated with higher 6-month mortality (adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P =.008), and longer hospital stay (adjusted HR, 2.0; 95% CI, 1.4-3.0; P<.001). Delirium in the ICU was also independently associated with a longer post-ICU stay (adjusted HR, 1.6; 95% CI, 1.2-2.3; P =.009), fewer median days alive and without mechanical ventilation (19 [interquartile range, 4-23] vs 24 [19-26]; adjusted P =.03), and a higher incidence of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P =.002). CONCLUSION: Delirium was an independent predictor of higher 6-month mortality and longer hospital stay even after adjusting for relevant covariates including coma, sedatives, and analgesics in patients receiving mechanical ventilation.
PMID: 15082703 [PubMed - indexed for MEDLINE]
Comment on:
Glucocorticoid therapy in the intensive care unit.
Loriaux L.
Division of Endocrinology, Diabetes, and Clinical Nutrition, Oregon Health and Sciences University, Portland, USA.
Publication Types:
PMID: 15084691 [PubMed - indexed for MEDLINE]
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