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Lorente L, Sabater-Riera J, Rello J. Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events. Expert Rev Anti Infect Ther 2024; 22:317-332. [PMID: 38642072 DOI: 10.1080/14787210.2024.2345877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Joan Sabater-Riera
- IDIBELL, Hospitalet de Llobregat, Spain, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Rello
- CRIPS (Clinical Research in Pneumonia & Sepsis); Vall d'Hebron Institute of Research, Barcelona, Spain
- Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Zhu D, Zhao Q, Guo S, Bai L, Yang S, Zhao Y, Xu Y, Zhou X. Efficacy of preventive interventions against ventilator-associated pneumonia in critically ill patients: an umbrella review of meta-analyses. J Hosp Infect 2024; 145:174-186. [PMID: 38295905 DOI: 10.1016/j.jhin.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/26/2023] [Indexed: 02/15/2024]
Abstract
Many meta-analyses have assessed the efficacy of preventive interventions against ventilator-associated pneumonia (VAP) in critically ill patients. However, there has been no comprehensive analysis of the strength and quality of evidence to date. Systematic reviews of randomized and quasi-randomized controlled trials, which evaluated the effect of preventive strategies on the incidence of VAP in critically ill patients receiving mechanical ventilation for at least 48 h, were included in this article. We identified a total of 34 interventions derived from 31 studies. Among these interventions, 19 resulted in a significantly reduced incidence of VAP. Among numerous strategies, only selective decontamination of the digestive tract (SDD) was supported by highly suggestive (Class II) evidence (risk ratio (RR)=0.439, 95% CI: 0.362-0.532). Based on data from the sensitivity analysis, the evidence for the efficacy of non-invasive ventilation in weaning from mechanical ventilation (NIV) was upgraded from weak (Class IV) to highly suggestive (Class II) (RR=0.32, 95% CI: 0.22-0.46). All preventive interventions were not supported by robust evidence for reducing mortality. Early mobilization exhibited suggestive (Class III) evidence in shortening both intensive length of stay (LOS) in the intensive care unit (ICU) (mean difference (MD)=-0.85, 95% CI: -1.21 to -0.49) and duration of mechanical ventilation (MD=-1.02, 95% CI: -1.41 to -0.63). In conclusion, SDD and NIV are supported by robust evidence for prevention against VAP, while early mobilization has been shown to significantly shorten the LOS in the ICU and the duration of mechanical ventilation. These three strategies are recommendable for inclusion in the ventilator bundle to lower the risk of VAP and improve the prognosis of critically ill patients.
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Affiliation(s)
- D Zhu
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Q Zhao
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - S Guo
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - L Bai
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - S Yang
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Y Zhao
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Y Xu
- School of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, China.
| | - X Zhou
- Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; Department of Respiratory and Critical Care Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China.
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Yokose M, Takaki S, Saigusa Y, Mihara T, Ishiwata Y, Kato S, Horie K, Goto T. Stomach position evaluated using computed tomography is related to successful post-pyloric enteral feeding tube placement in critically ill patients: a retrospective observational study. J Intensive Care 2023; 11:25. [PMID: 37254206 DOI: 10.1186/s40560-023-00673-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Post-pyloric enteral feeding reduces respiratory complications and shortens the duration of mechanical ventilation. Blind placement of post-pyloric enteral feeding tubes (EFT) in patients with critical illnesses is often the first-line method because endoscopy or fluoroscopy cannot be easily performed at bedside; however, difficult placements regularly occur. We reported an association between the stomach position caudal to spinal level L1-L2, evaluated by abdominal radiographs after placement, and difficult placement; however, this method could not indicate difficulty before EFT placement. The aim of our study was to evaluate the association between stomach position, estimated using computed tomography (CT) images taken before the blind placement of the post-pyloric EFT, and the difficulty of EFT placement. METHODS Data from patients aged ≥ 20 years who underwent post-pyloric EFT in our intensive care unit were obtained retrospectively. Logistic regression analysis was used to evaluate the association between successful initial EFT placement and explanatory variables, including stomach position estimated by CT. Two cut-off values were used: caudal to L1-L2 based on a previous study and the best cut-off value calculated by the receiver operating characteristic curve. Variable selection was performed backward stepwise using Akaike's Information Criterion. RESULTS Of the total of 453 patients who were enrolled, the success rate of the initial EFT placement was 43.5%. The adjusted odds ratio for successful initial EFT placement of the stomach position caudal to L1-L2 was 0.61 (95% confidence interval: 0.41-1.07). Logistic regression analysis, including the stomach position caudal to L2-L3, calculated as the best cut-off value, indicated that stomach position was an independent factor for failure of initial EFT placement (adjusted odds ratio, 0.55; 95% confidence interval: 0.33-0.91). CONCLUSIONS Stomach position evaluated using CT images was associated with successful initial post-pyloric EFT placement. The best cut-off value of the greater curvature of the stomach to predict the success or failure of the first attempt was spinal level L2-L3. Trial registration University Hospital Medical Information Network Clinical Trials Registry (UMIN000046986; February 28, 2022). https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000052151.
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Affiliation(s)
- Masashi Yokose
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Japan.
| | - Shunsuke Takaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Japan
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Yoshinobu Ishiwata
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shingo Kato
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keiichi Horie
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Japan
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Candida and the Gram-positive trio: testing the vibe in the ICU patient microbiome using structural equation modelling of literature derived data. Emerg Themes Epidemiol 2022; 19:7. [PMID: 35982466 PMCID: PMC9387012 DOI: 10.1186/s12982-022-00116-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Whether Candida interacts with Gram-positive bacteria, such as Staphylococcus aureus, coagulase negative Staphylococci (CNS) and Enterococci, to enhance their invasive potential from the microbiome of ICU patients remains unclear. Several effective anti-septic, antibiotic, anti-fungal, and non-decontamination based interventions studied for prevention of ventilator associated pneumonia (VAP) and other ICU acquired infections among patients receiving prolonged mechanical ventilation (MV) are known to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies enables tests of these postulated microbial interactions in the clinical context. Methods Four candidate generalized structural equation models (GSEM), each with Staphylococcus aureus, CNS and Enterococci colonization, defined as latent variables, were confronted with blood culture and respiratory tract isolate data derived from 460 groups of ICU patients receiving prolonged MV from 283 infection prevention studies. Results Introducing interaction terms between Candida colonization and each of S aureus (coefficient + 0.40; 95% confidence interval + 0.24 to + 0.55), CNS (+ 0.68; + 0.34 to + 1.0) and Enterococcal (+ 0.56; + 0.33 to + 0.79) colonization (all as latent variables) improved the fit for each model. The magnitude and significance level of the interaction terms were similar to the positive associations between exposure to topical antibiotic prophylaxis (TAP) on Enterococcal (+ 0.51; + 0.12 to + 0.89) and Candida colonization (+ 0.98; + 0.35 to + 1.61) versus the negative association of TAP with S aureus (− 0.45; − 0.70 to − 0.20) colonization and the negative association of anti-fungal exposure and Candida colonization (− 1.41; − 1.6 to − 0.72). Conclusions GSEM modelling of published ICU infection prevention data enables the postulated interactions between Candida and Gram-positive bacteria to be tested using clinically derived data. The optimal model implies interactions occurring in the human microbiome facilitating bacterial invasion and infection. This interaction might also account for the paradoxically high bacteremia incidences among studies of TAP in ICU patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12982-022-00116-9. GSEM modelling of published ICU infection prevention data from > 250 studies enables a test of and provides support to the interaction between Candida and Gram-positive bacteria. The various ICU infection prevention interventions may each broadly impact the patient microbiome.
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Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
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Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
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Comparison of nutritional effectiveness and complication rate between early nasojejunal and nasogastric tube feeding in patients with an intracerebral hemorrhage. J Clin Neurosci 2022; 103:107-111. [PMID: 35868226 DOI: 10.1016/j.jocn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/21/2022] [Accepted: 07/09/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study aimed to compare nutritional effectiveness and complication rate between early nasojejunal and nasogastric tube feeding in patients with an intracerebral hemorrhage. METHODS This was a retrospective study. Eighty patients with an intracerebral hemorrhage were divided into a nasojejunal and a nasogastric tube feeding group. Feeding tubes were placed within 6 h after admission, and enteral feeding began within 2 h after tube placement. The nutritional status and complication rate of the 2 groups were compared before and 2 and 4 weeks after beginning feeding. RESULTS Serum prealbumin, serum albumin, and hemoglobin levels were significantly higher in the nasojejunal tube feeding group than in the nasogastric tube feeding group at 2 and 4 weeks after beginning feeding (all, p < 0.05). The incidence of gastric retention, pulmonary aspiration, and pneumonia were lower in the early nasojejunal tube feeding group than in the early nasogastric tube feeding group (all, p < 0.05). There was no significant difference in the incidence of diarrhea between the 2 groups. CONCLUSION Compared with early nasogastric feeding, early nasojejunal feeding provides better nutritional effectiveness and a lower incidence of gastric retention, pulmonary aspiration, and pneumonia in patients with an intracerebral hemorrhage.
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M. Patil S. Hospital-Acquired Pneumonia. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pneumonia acquired during hospitalization is called nosocomial pneumonia (NP). Nosocomial pneumonia is divided into two types. Hospital-acquired pneumonia (HAP) refers to hospital-acquired pneumonia, whereas ventilator-associated pneumonia (VAP) refers to ventilator-associated pneumonia. Most clinical literature stresses VAP’s importance and associated mortality and morbidity, whereas HAP is not given enough attention even while being the most common cause of NP. HAP, like VAP, carries a high mortality and morbidity. HAP is the commonest cause of mortality from hospital-acquired infections. HAP is a common determinant for intensive care unit (ICU) admits with respiratory failure. Recent research has identified definite risk factors responsible for HAP. If these are prevented or modified, the HAP incidence can be significantly decreased with improved clinical outcomes and lesser utilization of the health care resources. The prevention approach will need multiple strategies to address the issues. Precise epidemiological data on HAP is deficient due to limitations of the commonly used diagnostic measures. The diagnostic modalities available in HAP are less invasive than VAP. Recent infectious disease society guidelines have stressed the importance of HAP by removing healthcare-associated pneumonia as a diagnosis. Specific differences exist between HAP and VAP, which are gleaned over in this chapter.
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Lu G, Xiang Q, Wang S, Pan M, Xiang X, Yang Y, Shi X. Endoscopic- versus x-ray-guidance for placement of nasojejunal tubes in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Am J Transl Res 2022; 14:2134-2146. [PMID: 35559401 PMCID: PMC9091079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 03/22/2022] [Indexed: 06/15/2023]
Abstract
Nasojejunal tubes (NJTs) are increasingly used in critically ill patients. NJT insertion with endoscopic- or x-ray-guidance can be achieved with success rates above 90%. This systematic review and meta-analysis of randomized controlled trials (RCTs) compares the efficiency and safety of these two methods in critically ill patients. We searched Chinese and English databases for RCTs comparing endoscopy- and x-ray-guided NJT placement published up to July 5, 2021. Meta-analyses were performed using RevMan5 software to compute mean differences (MDs) and odds ratios (ORs). Eleven RCTs (n=676) were included. The endoscopic group had a higher procedure success rate (OR=2.14, 95% CI [1.19, 3.85], Z=2.52, P=0.01) and shorter insertion time (MD=-3.70 min, 95% CI [-6.90, -0.50], Z=2.27, P=0.02) than the x-ray group. NJT indwelling time and post-insertion complications were similar between groups. The x-ray group had fewer complications during placement (OR=8.08, 95% CI [3.58, 18.22], Z=5.03, P<0.00001]; on subgroup analysis, only gastrointestinal non-bleeding adverse events differed significantly between groups (OR=2.78, 95% CI [1.43, 5.39], Z=3.03, P=0.002). Visual analog scale discomfort scores were better in the x-ray group (MD=4.10, 95% CI [3.57, 4.63], Z=15.07, P<0.00001). Compared with x-ray-guided NJT placement, endoscopy-guided placement was faster, had a higher success rate, and was associated with fewer gastrointestinal non-bleeding adverse events and less discomfort during insertion. Endoscopic guidance is recommended for NJT placement in critically ill patients to improve placement efficiency. X-ray guidance is a good alternative, depending on the hospital setting, as it is convenient, economical, and potentially safer.
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Affiliation(s)
- Guanzhen Lu
- Surgery Department, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Qin Xiang
- Graduate School of Nursing, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Sha Wang
- Graduate School of Nursing, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Mingyue Pan
- Graduate School of Nursing, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Xu Xiang
- Graduate School of Nursing, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Yanling Yang
- Graduate School of Nursing, Huzhou UniversityHuzhou 313000, Zhejiang, China
| | - Xinyan Shi
- Surgery Department, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou UniversityHuzhou 313000, Zhejiang, China
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Deng LX, Lan-Cao, Zhang LN, Dun-Tian, Yang-Sun, Qing-Yang, Yan-Huang. The effects of abdominal-based early progressive mobilisation on gastric motility in endotracheally intubated intensive care patients: A randomised controlled trial. Intensive Crit Care Nurs 2022; 71:103232. [DOI: 10.1016/j.iccn.2022.103232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 02/08/2023]
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Bond A, Czapran A, Lal S. Small bowel feeding: do you pay the price for bypassing the stomach? Curr Opin Clin Nutr Metab Care 2022; 25:116-121. [PMID: 34966116 DOI: 10.1097/mco.0000000000000804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians. RECENT FINDINGS Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function. SUMMARY The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.
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Affiliation(s)
- Ashley Bond
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford
| | - Adam Czapran
- Department of Critical Care, Kings College NHS Foundation Trust, London
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford
- University of Manchester, Manchester, UK
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Wang H, Huang C, Yang Y, Kong L, Zheng X, Shan X. Cost-effectiveness analysis of nasojejunal tube feeding for the prevention of pneumonia in critically ill adults. JPEN J Parenter Enteral Nutr 2021; 46:1167-1175. [PMID: 34751960 DOI: 10.1002/jpen.2302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Nasojejunal tube (NJT) feeding has demonstrated value in reducing pneumonia in critically ill adults who require enteral nutritional (EN) support. This study discusses whether EN support via nasojejunal tube (NJT) feeding is more cost-effective than nasogastric tube (NGT) feeding in reducing pneumonia. METHODS A decision tree model was created. The analysis was based on data from a health care provider in China. Model inputs were derived from published data. The endpoints included incremental cost per pneumonia infection avoided, incremental cost-effectiveness ratio (ICER), net monetary benefit (NMB) and incremental net monetary benefit (INMB) associated with prevention of pneumonia. The uncertainty was assessed through one-way and probabilistic sensitivity analysis. RESULTS The base case analysis showed that EN support via NJT feeding resulted in 0.7453 quality-adjusted life years (QALYs) at a cost of $3018.83 compared to NGT feeding, which resulted in 0.7354 QALYs at a cost of $4788.76. NJT feeding was better than NGT feeding, providing an INMB of $2,075.09 and an ICER of $-178,813.96 per QALY gained, and the cost per pneumonia infection prevented was $16,808.51. The probabilistic sensitivity analysis indicated that NJT feeding was more cost-effective in 83.4% of the cases, with a cost below the WTP threshold. The NMB and INMB estimation for different WTP thresholds also indicated that NJT feeding is the optimal strategy. CONCLUSIONS EN support via NJT feeding was a more cost-effective strategy than NGT feeding in preventing pneumonia in critically ill adults. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hongmei Wang
- Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chun Huang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yang Yang
- Operating Room, VIP Department, Jinshan Hospital, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 401122, China
| | - Lingxi Kong
- Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiaoying Zheng
- Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xuefeng Shan
- Department of Pharmacy, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
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Kurisawa K, Yokose M, Tanaka H, Mihara T, Takaki S, Goto T. Multivariate analysis of factors associated with first-pass success in blind placement of a post-pyloric feeding tube: a retrospective study. J Intensive Care 2021; 9:59. [PMID: 34615558 PMCID: PMC8494630 DOI: 10.1186/s40560-021-00577-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trans-jejunal nutrition via a post-pyloric enteral feeding tube has a low risk of aspiration or reflux; however, placement of the tube using the blind method can be difficult. Assistive devices, such as fluoroscopy or endoscopy, are useful but may not be suitable for patients with hemodynamic instability or severe respiratory failure. The aim of this study was to explore factors associated with first-pass success in the blind placement of post-pyloric enteral feeding tubes in critically ill patients. METHODS Data were obtained retrospectively from the medical records of adult patients who had a post-pyloric enteral feeding tube placed in the intensive care unit between January 1, 2012, and December 31, 2018. Logistic regression analysis was performed to assess the association between first-pass success and the independent variables. For logistic regression analysis, the following 13 variables were defined as independent variables: age, sex, height, fluid balance from baseline, use of sedatives, body position during the procedure, use of cardiac assist devices, use of prokinetic agents, presence or absence of intestinal peristalsis, postoperative cardiovascular surgery, use of renal replacement therapy, serum albumin levels, and position of the greater curvature of the stomach in relation to spinal levels L1 - L2. RESULTS Data obtained from 442 patients were analyzed. The first-pass success rate was 42.8% (n = 189). Logistic regression analysis demonstrated that the position of the greater curvature of the stomach cephalad to L1 - L2 was only associated with successful placement (odds ratio for first-pass success, 0.62; 95% confidence interval: 0.40 - 0.95). CONCLUSIONS In critically ill patients, the position of the greater curvature of the stomach caudal to L1 - L2 may be associated with a lower first-pass success rate of the blind method for post-pyloric enteral feeding tube placement. Further studies are needed to verify our results because the position of the stomach was estimated by radiographs after enteral feeding tube placement. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trials Registry (UMIN000036549; April 20, 2019).
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Affiliation(s)
- Kohei Kurisawa
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Masashi Yokose
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.
| | - Hiroyuki Tanaka
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Shunsuke Takaki
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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13
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Wei M, Ho E, Hegde P. An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit. J Thorac Dis 2021; 13:5277-5296. [PMID: 34527366 PMCID: PMC8411178 DOI: 10.21037/jtd-19-3728] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023]
Abstract
Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.
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Affiliation(s)
- Margaret Wei
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Elliot Ho
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
| | - Pravachan Hegde
- Division of Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, University of California San Francisco - Fresno, Fresno, CA, USA
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14
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Liu Y, Wang Y, Zhang B, Wang J, Sun L, Xiao Q. Gastric-tube versus post-pyloric feeding in critical patients: a systematic review and meta-analysis of pulmonary aspiration- and nutrition-related outcomes. Eur J Clin Nutr 2021; 75:1337-1348. [PMID: 33536570 DOI: 10.1038/s41430-021-00860-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 11/20/2020] [Accepted: 01/07/2021] [Indexed: 01/30/2023]
Abstract
Gastric-tube feeding and post-pyloric feeding are the two most common forms of enteral nutrition, each with advantages and disadvantages. To explore the effects and safety of gastric-tube versus post-pyloric feeding in critical patients by comparing pulmonary aspiration- and nutrition-related outcomes, a meta-analysis was conducted. It was performed by systematically searching the following databases: PubMed, EMBASE, Cochrane library, BMJ best practice, ProQuest dissertations and theses, CINAHL, web of science, SinoMed, WANFANG, CNKI, and the platform of clinical trial registration. The databases were searched through December 31, 2019, and studies were evaluated by two independent researchers. Review Manager software was used for data analysis. We included 41 studies conducted in ten countries and involving 3248 participants. Meta-analysis showed that post-pyloric feeding had a lower incidence rate of pulmonary aspiration, gastric reflux, and pneumonia (P < 0.001, all), less incidence of gastrointestinal complications including vomiting, nausea, diarrhea, abdominal distension, high gastric residual volume, and constipation (P < 0.05, all), more optimal gastrointestinal nutrition including the percentage of total nutrition provided to the patient, the time to tolerate enteral nutrition, the time required to start feeding and the time required to reach nutritional targets (P < 0.05, all), shorter length of mechanical ventilation, stay in ICU and stay in hospital (P < 0.001, all), compared with gastric-tube feeding. No significant differences were shown in the time of gastrointestinal function recovery, mortality, or hospitalization expenses between the two feeding routes. This review provides evidence that post-pyloric feeding appears to be the safer and more effective choice, as compared to gastric-tube feeding among critical patients.
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Affiliation(s)
- Yue Liu
- School of Nursing, Capital Medical University, Beijing, 100069, China
| | - Yanling Wang
- School of Nursing, Capital Medical University, Beijing, 100069, China
| | - Bohan Zhang
- School of Nursing, Capital Medical University, Beijing, 100069, China
| | - Jiani Wang
- School of Nursing, Capital Medical University, Beijing, 100069, China
| | - Liu Sun
- School of Nursing, Capital Medical University, Beijing, 100069, China
| | - Qian Xiao
- School of Nursing, Capital Medical University, Beijing, 100069, China.
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15
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Asymmetric Effects of Decontamination Using Topical Antibiotics for the ICU Patient. Symmetry (Basel) 2021. [DOI: 10.3390/sym13061027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in >200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.
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16
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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17
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Bing X, Yinshan T, Ying J, Yingchuan S. Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial. J Int Med Res 2021; 49:300060521992183. [PMID: 33622069 PMCID: PMC7907950 DOI: 10.1177/0300060521992183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective To compare the efficacy and safety of a new modified method of bedside
post-pyloric feeding tube catheterization with the Corpak protocol versus
electromagnetic-guided catheterization. Materials and Methods We conducted a single-center, single-blinded, prospective clinical trial.
Sixty-three patients were treated with a non-gravity type gastrointestinal
feeding tube using different procedures: modified bedside post-pyloric
feeding tube placement (M group), the conventional Corpak protocol (C
group), and standard electromagnetic-guided tube placement (EM group). Results The success rate in the M group, C group, and EM group was 82.9% (34/41),
70.7% (29/41), and 88.2% (15/17), respectively, with significant differences
among the groups. The time required to pass the pylorus was significantly
shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and
EM group (42.1 minutes). The proportion of pylorus-passing operations
completed within 30 minutes was significantly higher in the M group than in
the C group and EM group. No severe complications occurred. Conclusion This modified method of bedside post-pyloric feeding tube catheterization
significantly shortened the time required to pass the pylorus with no severe
adverse reactions. This method is effective and safe for enteral nutrition
catheterization of patients with dysphagia and a high risk of aspiration
pneumonia.
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Affiliation(s)
- Xiong Bing
- Department of Rehabilitation, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Tang Yinshan
- Department of Rehabilitation, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Jin Ying
- Department of Rehabilitation, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
| | - Shen Yingchuan
- Department of Radiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, PR China
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18
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. Design A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. Methods The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. Results The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified. Conclusions A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore.,Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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19
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Candida- Acinetobacter-Pseudomonas Interaction Modelled within 286 ICU Infection Prevention Studies. J Fungi (Basel) 2020; 6:jof6040252. [PMID: 33121074 PMCID: PMC7712580 DOI: 10.3390/jof6040252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Whether Candida interacts to enhance the invasive potential of Acinetobacter and Pseudomonas bacteria cannot be resolved within individual studies. There are several anti-septic, antibiotic, anti-fungal, and non-decontamination-based interventions to prevent ICU acquired infection. These effective prevention interventions would be expected to variably impact Candida colonization. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-centre natural experiment with which to evaluate Candida, Acinetobacter and Pseudomonas interaction (CAPI). METHODS Eight Candidate-generalized structural equation models (GSEM), with Candida, Pseudomonas and Acinetobacter colonization as latent variables, were confronted with blood culture and respiratory tract isolate data derived from >400 groups derived from 286 infection prevention studies. RESULTS Introducing an interaction term between Candida colonization and each of Pseudomonas and Acinetobacter colonization improved model fit in each case. The size of the coefficients (and 95% confidence intervals) for these interaction terms in the optimal Pseudomonas (+0.33; 0.22 to 0.45) and Acinetobacter models (+0.32; 0.01 to 0.5) were similar to each other and similar in magnitude, but contrary in direction, to the coefficient for exposure to topical antibiotic prophylaxis (TAP) on Pseudomonas colonization (-0.45; -0.71 to -0.2). The coefficient for exposure to topical antibiotic prophylaxis on Acinetobacter colonization was not significant. CONCLUSIONS GSEM modelling of published ICU infection prevention data supports the CAPI concept. The CAPI model could account for some paradoxically high Acinetobacter and Pseudomonas infection incidences, most apparent among the concurrent control groups of TAP studies.
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20
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 473] [Impact Index Per Article: 118.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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21
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Liu D, Xu Z, Qu C, Huo B, Lai H, Li Y, Liu B, Deng H, Wang Q, Li D, Chang P, Li S, Wang H. [Efficacy and safety of early physical therapy for acute gastrointestinal injury during mechanical ventilation in patients with sepsis: a randomized controlled pilot trial]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:1298-1304. [PMID: 31852650 DOI: 10.12122/j.issn.1673-4254.2019.11.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the therapeutic effect and safety of early physical therapy for acute gastrointestinal injury (AGI) in septic patients receiving mechanical ventilation. METHODS A randomized controlled trial was conducted in the ICU of a tertiary teaching hospital from May, 2017 to March, 2018. The patients diagnosed with sepsis complicated by AGI during mechanical ventilation were recruited and block-randomized into intervention group and control group. Both groups received standard therapy of sepsis, and the patients in the intervention group also received physical therapy as soon as they were hemodynamically stable. The outcome measures included the recovery of AGI, ICU mortality, duration and outcomes of mechanical ventilation and the length of ICU stay. RESULTS A total of 60 patients were initially included, and 34 of them completed the study, including 16 in the intervention group and 18 in the control group. After physical rehabilitation, the number of patients with a cure of AGI did not significantly differ between the two group (P > 0.05). Nonetheless, the reduction of AGI scores after the treatments differed significantly between the intervention group and the control group (-1.9±2.1 vs 0.9± 1.6, P < 0.05). No significant differences were found between the two groups in ICU mortality, duration and outcomes of mechanical ventilation, or the length of ICU stay (P > 0.05). In the intervention group, the incidence of exercise-related adverse events was 3.33%, and severe organ injury or death occurred in none of patients. CONCLUSIONS Early rehabilitation therapy does not reduce the incidence of AGI but can lower AGI scores and alleviate gastrointestinal symptoms in patients with sepsis during mechanical ventilation. The results still await further verification by welldesigned multicenter clinical trials with large sample sizes.
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Affiliation(s)
- Danlei Liu
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Zhouqian Xu
- Department of Intensive Care Medicine, Huaduo Hospital Affiliated to Southern Medical University, Guangzhou 510800, China
| | - Changchun Qu
- Department of Intensive Care Medicine, Yunfu People's Hospital, Yunfu 527300, China
| | - Baoshan Huo
- Department of Intensive Care Medicine, Foshan Second People's Hospital, Foshan 528000, China
| | - Hanqi Lai
- Department of Intensive Care Medicine, Puning Overseas Chinese Hospital, Puning 515300, China
| | - Yang Li
- Department of Intensive Care Medicine, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, China
| | - Bin Liu
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Huojin Deng
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Qianwen Wang
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Dujuan Li
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Ping Chang
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Sha Li
- Department of Intensive Care Medicine, Fifth Affiliated Hospital of Southern Medical University, Guangzhou 510900, China
| | - Hua Wang
- Department of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
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22
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Abstract
PURPOSE OF REVIEW Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental. RECENT FINDINGS Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens. SUMMARY Most potential HAP prevention strategies remain unproven.
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Bear DE, Champion A, Lei K, Camporota L, Barrett NA. Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care. ACTA ACUST UNITED AC 2019; 26:1008-1015. [PMID: 29034711 DOI: 10.12968/bjon.2017.26.18.1008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.
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Affiliation(s)
- Danielle E Bear
- Principal Critical Care Dietitian, Department of Critical Care and Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London
| | - Alice Champion
- Specialist Dietitian, Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London
| | - Katie Lei
- Research Nurse, Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London
| | - Luigi Camporota
- Consultant in Critical Care, Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London
| | - Nicholas A Barrett
- Consultant in Critical Care, Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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A comparative study of risk of pneumonia and mortalities between nasogastric and jejunostomy feeding routes in surgical critically ill patients with perforated peptic ulcer. PLoS One 2019; 14:e0219258. [PMID: 31269088 PMCID: PMC6608947 DOI: 10.1371/journal.pone.0219258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Enteral nutrition (EN) is important in the management of critically illness. Yet, the best route (e.g. pre-pyloric or post-pyloric) for EN in critically ill patients remains to be investigated, especially in specific surgical patients group. In addition, EN could be associated with a higher risk of aspiration pneumonia. Therefore, we evaluate the effect of various EN routes in surgical critically ill perforated peptic ulcer (PPU) patients who underwent surgery and required mechanical ventilation. METHOD We collected data of surgical critically ill PPU patients admitted to intensive care unit. The patients were managed with appropriate care bundle and program. To reduce the impact of surgery types, we excluded those who had received other surgical procedures and included patients that only received simple closure. Patients were classified into nasogastric and jejunostomy feeding groups. The demographics, severity scores (e.g.: APACHE II, SOFA, and POSSUM), body mass index (BMI), comorbidities, ventilator days, use of proton pump inhibitors (PPIs), pneumonia occurrence, mortality and complications were collected for analysis. RESULTS A total of 136 critically ill PPU patients that received surgery and mechanical ventilation were enrolled. There were 53 patients in NG group and 83 patients in FJ group. There were no differences in demographics, severity scores, BMI, comorbidities, ventilator days, use of PPIs, pneumonia occurrence, mortalities and complications between groups. CONCLUSION Our study indicates that there are no differences in mortalities and pneumonia occurrence using nasogastric or feeding jejunostomy in surgical critically ill PPU patients underwent surgery. However, further studies are required.
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Seitz AP, Schumacher F, Baker J, Soddemann M, Wilker B, Caldwell CC, Gobble RM, Kamler M, Becker KA, Beck S, Kleuser B, Edwards MJ, Gulbins E. Sphingosine-coating of plastic surfaces prevents ventilator-associated pneumonia. J Mol Med (Berl) 2019; 97:1195-1211. [PMID: 31222488 PMCID: PMC6647234 DOI: 10.1007/s00109-019-01800-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality in critically ill patients. Here, we employed the broad antibacterial effects of sphingosine to prevent VAP by developing a novel method of coating surfaces of endotracheal tubes with sphingosine and sphingosine analogs. Sphingosine and phytosphingosine coatings of endotracheal tubes prevent adherence and mediate killing of Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus, even in biofilms. Most importantly, sphingosine-coating of endotracheal tubes also prevented P. aeruginosa and S. aureus pneumonia in vivo. Coating of the tubes with sphingosine was stable, without obvious side effects on tracheal epithelial cells and did not induce inflammation. In summary, we describe a novel method to coat plastic surfaces and provide evidence for the application of sphingosine and phytosphingosine as novel antimicrobial coatings to prevent bacterial adherence and induce killing of pathogens on the surface of endotracheal tubes with potential to prevent biofilm formation and VAP. KEY MESSAGES: Novel dip-coating method to coat plastic surfaces with lipids. Sphingosine and phytosphingosine as novel antimicrobial coatings on plastic surface. Sphingosine coatings of endotracheal tubes prevent bacterial adherence and biofilms. Sphingosine coatings of endotracheal tubes induce killing of pathogens. Sphingosine coatings of endotracheal tubes ventilator-associated pneumonia.
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Affiliation(s)
- Aaron P Seitz
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA.
| | - Fabian Schumacher
- Institute of Nutritional Science, Department of Toxicology, University of Potsdam, Arthur-Scheunert-Allee 114-116, 14558, Nuthetal, Germany.,Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Jennifer Baker
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA
| | - Matthias Soddemann
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Barbara Wilker
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Charles C Caldwell
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA.,Division of Research, Shriners Hospital for Children, Cincinnati, OH, 45229, USA
| | - Ryan M Gobble
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA
| | - Markus Kamler
- Thoracic Transplantation, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Katrin Anne Becker
- Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Sascha Beck
- Orthopedic Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Burkhard Kleuser
- Institute of Nutritional Science, Department of Toxicology, University of Potsdam, Arthur-Scheunert-Allee 114-116, 14558, Nuthetal, Germany
| | - Michael J Edwards
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA
| | - Erich Gulbins
- Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way ML 0558, Cincinnati, OH, 45267, USA. .,Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1254] [Impact Index Per Article: 209.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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Incidences of Pseudomonas aeruginosa-Associated Ventilator-Associated Pneumonia within Studies of Respiratory Tract Applications of Polymyxin: Testing the Stoutenbeek Concurrency Postulates. Antimicrob Agents Chemother 2018; 62:AAC.00291-18. [PMID: 29784844 DOI: 10.1128/aac.00291-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/10/2018] [Indexed: 01/18/2023] Open
Abstract
Regimens containing topical polymyxin appear highly effective at preventing ventilator-associated pneumonia (VAP) overall and, more so, VAP caused by Gram-negative bacteria. However, Stoutenbeek's postulates that VAP incidences within studies of topical antibiotics depend on the context of whether the component (control and intervention) groups of each study were concurrent versus nonconcurrent remain untested. The literature was searched for concurrent control (CC) versus nonconcurrent control (NCC) designed studies of respiratory tract applications of topical polymyxin to mechanically ventilated (MV) patients that reported incidences of Pseudomonas-associated ventilator-associated pneumonia (PsVAP). Studies of various interventions other than topical polymyxin (nonpolymyxin studies) served to provide additional points of reference. The PsVAP incidences within the component groups of all studies were benchmarked against groups from observational studies. This was undertaken by meta-regression using generalized estimating equation methods. Dot plots, caterpillar plots, and funnel plots enable visual benchmarking. The PsVAP benchmark (and 95% confidence interval [CI]) derived from 102 observational groups is 4.6% (4.0 to 5.3%). In contrast, the mean PsVAP within NCC polymyxin intervention groups (1.6%; CI, 1.0 to 4.5%) is lower than that of all other component group categories. The mean PsVAP within CC polymyxin control groups (9.9%; CI, 7.6 to 12.8%) is higher than that of all other component group categories. The PsVAP incidences of control and intervention groups of studies of respiratory tract applications of polymyxin are dependent on whether the groups were within a concurrent versus nonconcurrent study. Stoutenbeek's concurrency postulates are validated.
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Hurley JC. Paradoxical Acinetobacter-associated ventilator-associated pneumonia incidence rates within prevention studies using respiratory tract applications of topical polymyxin: benchmarking the evidence base. J Hosp Infect 2018; 100:105-113. [PMID: 29649555 DOI: 10.1016/j.jhin.2018.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Regimens containing topical polymyxin appear to be more effective in preventing ventilator-associated pneumonia (VAP) than other methods. AIM To benchmark the incidence rates of Acinetobacter-associated VAP (AAVAP) within component (control and intervention) groups from concurrent controlled studies of polymyxin compared with studies of various VAP prevention methods other than polymyxin (non-polymyxin studies). METHODS An AAVAP benchmark was derived using data from 77 observational groups without any VAP prevention method under study. Data from 41 non-polymyxin studies provided additional points of reference. The benchmarking was undertaken by meta-regression using generalized estimating equation methods. RESULTS Within 20 studies of topical polymyxin, the mean AAVAP was 4.6% [95% confidence interval (CI) 3.0-6.9] and 3.7% (95% CI 2.0-5.3) for control and intervention groups, respectively. In contrast, the AAVAP benchmark was 1.5% (95% CI 1.2-2.0). In the AAVAP meta-regression model, group origin from a trauma intensive care unit (+0.55; +0.16 to +0.94, P = 0.006) or membership of a polymyxin control group (+0.64; +0.21 to +1.31, P = 0.023), but not membership of a polymyxin intervention group (+0.24; -0.37 to +0.84, P = 0.45), were significant positive correlates. CONCLUSIONS The mean incidence of AAVAP within the control groups of studies of topical polymyxin is more than double the benchmark, whereas the incidence rates within the groups of non-polymyxin studies and, paradoxically, polymyxin intervention groups are more similar to the benchmark. These incidence rates, which are paradoxical in the context of an apparent effect against VAP within controlled trials of topical polymyxin-based interventions, force a re-appraisal.
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Affiliation(s)
- J C Hurley
- Rural Health Academic Centre, Melbourne Medical School, University of Melbourne, Victoria, Australia; Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.
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Unusually High Incidences of Staphylococcus aureus Infection within Studies of Ventilator Associated Pneumonia Prevention Using Topical Antibiotics: Benchmarking the Evidence Base. Microorganisms 2018; 6:microorganisms6010002. [PMID: 29300363 PMCID: PMC5874616 DOI: 10.3390/microorganisms6010002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/29/2017] [Accepted: 01/02/2018] [Indexed: 01/08/2023] Open
Abstract
Selective digestive decontamination (SDD, topical antibiotic regimens applied to the respiratory tract) appears effective for preventing ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients. However, potential contextual effects of SDD on Staphylococcus aureus infections in the ICU remain unclear. The S. aureus ventilator associated pneumonia (S. aureus VAP), VAP overall and S. aureus bacteremia incidences within component (control and intervention) groups within 27 SDD studies were benchmarked against 115 observational groups. Component groups from 66 studies of various interventions other than SDD provided additional points of reference. In 27 SDD study control groups, the mean S. aureus VAP incidence is 9.6% (95% CI; 6.9–13.2) versus a benchmark derived from 115 observational groups being 4.8% (95% CI; 4.2–5.6). In nine SDD study control groups the mean S. aureus bacteremia incidence is 3.8% (95% CI; 2.1–5.7) versus a benchmark derived from 10 observational groups being 2.1% (95% CI; 1.1–4.1). The incidences of S. aureus VAP and S. aureus bacteremia within the control groups of SDD studies are each higher than literature derived benchmarks. Paradoxically, within the SDD intervention groups, the incidences of both S. aureus VAP and VAP overall are more similar to the benchmarks.
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Jiao H, Mei L, Liang C, Dai Y, Fu Z, Wu L, Sanvanson P, Shaker R. Upper esophageal sphincter augmentation reduces pharyngeal reflux in nasogastric tube-fed patients. Laryngoscope 2017; 128:1310-1315. [PMID: 28988414 DOI: 10.1002/lary.26895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2017] [Indexed: 01/25/2023]
Abstract
OBJECTIVES/HYPOTHESIS Aspiration of gastric refluxate is one of the most commonly observed complications among long-term nasogastric tube (NGT) fed patients. The upper esophageal sphincter (UES) pressure barrier is the main defense mechanism against pharyngeal reflux of gastric contents. Our objective was to investigate the efficacy and safety of the UES assist device (UES-AD) in preventing gastric reflux through the UES in long-term NGT-fed patients. STUDY DESIGN Self-Controlled Case series. METHODS We studied 10 patients (mean age = 90.6 ± 3.4 years, four females) with dysphagia caused by stroke or dementia who were fed for 0.5 to 5 years (median = 3 years) by NGT. External pressures of 20 to 30 mm Hg were applied by using a handmade UES-AD, which was started 2 hours after the beginning of NGT infusion and was alternated between periods of 2 hours on and 2 hours off, for a total of 12 hours. Placement of the impedance sensors within the UES was guided by high-resolution manometry. Trans-UES and intraesophageal reflux events were recorded by using 24-hour combined pH-impedance measurements. RESULTS No aspiration pneumonia events were noted in the period 1 month before or during the study in any of the cohort. Baseline UES pressure averaged 17.5 ± 9.4 mm Hg and was increased to 38.9 ± 11.9mm Hg after application of the UES-AD. Overall frequency of trans-UES reflux decreased significantly with the UES-AD compared to without (0.8 ± 0.9 vs. 3.3 ± 2.8, P < .05 for the 12-hour study period). There was no effect of the UES-AD on esophageal reflux events (7.4 ± 4.4 vs. 6.4 ± 3.0, P > .05). CONCLUSIONS UES-AD significantly decreases the number of trans-UES reflux events and can potentially reduce the aspiration risk associated with NGT feeding. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1310-1315, 2018.
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Affiliation(s)
- Hongmei Jiao
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Ling Mei
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Chenyang Liang
- Department of Radiology, Unicare ENT Hospital, Beijing, China
| | - Yun Dai
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Zhifang Fu
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Lihong Wu
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - Patrick Sanvanson
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Reza Shaker
- Department of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1883] [Impact Index Per Article: 269.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Lodewijkx PJ, Besselink MG, Witteman BJ, Schepers NJ, Gooszen HG, van Santvoort HC, Bakker OJ. Nutrition in acute pancreatitis: a critical review. Expert Rev Gastroenterol Hepatol 2017; 10:571-80. [PMID: 26823272 DOI: 10.1586/17474124.2016.1141048] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.
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Affiliation(s)
- Piet J Lodewijkx
- a Department of Surgery , Jeroen Bosch hospital , s-Hertogenbosch , The Netherlands
| | - Marc G Besselink
- b Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
| | - Ben J Witteman
- c Department of Gastroenterology and Hepatology , Hospital Gelderse Vallei Ede , Ede , The Netherlands
| | - Nicolien J Schepers
- d Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands.,e Department of Gastroenterology and Hepatology , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Hein G Gooszen
- f Department of Operating Theatres and Evidence Based Surgery , Radboud University Medical Center , Nijmegen , The Netherlands
| | | | - Olaf J Bakker
- g Department of Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3669] [Impact Index Per Article: 524.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Lewis K, Alqahtani Z, Mcintyre L, Almenawer S, Alshamsi F, Rhodes A, Evans L, Angus DC, Alhazzani W. The efficacy and safety of prokinetic agents in critically ill patients receiving enteral nutrition: a systematic review and meta-analysis of randomized trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:259. [PMID: 27527069 PMCID: PMC4986344 DOI: 10.1186/s13054-016-1441-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 07/26/2016] [Indexed: 12/26/2022]
Abstract
Background Intolerance to enteral nutrition is common in critically ill adults, and may result in significant morbidity including ileus, abdominal distension, vomiting and potential aspiration events. Prokinetic agents are prescribed to improve gastric emptying. However, the efficacy and safety of these agents in critically ill patients is not well-defined. Therefore, we conducted a systematic review and meta-analysis to determine the efficacy and safety of prokinetic agents in critically ill patients. Methods We searched MEDLINE, EMBASE, and Cochrane Library from inception up to January 2016. Eligible studies included randomized controlled trials (RCTs) of critically ill adults assigned to receive a prokinetic agent or placebo, and that reported relevant clinical outcomes. Two independent reviewers screened potentially eligible articles, selected eligible studies, and abstracted pertinent data. We calculated pooled relative risk (RR) for dichotomous outcomes and mean difference for continuous outcomes, with the corresponding 95 % confidence interval (CI). We assessed risk of bias using Cochrane risk of bias tool, and the quality of evidence using grading of recommendations assessment, development, and evaluation (GRADE) methodology. Results Thirteen RCTs (enrolling 1341 patients) met our inclusion criteria. Prokinetic agents significantly reduced feeding intolerance (RR 0.73, 95 % CI 0.55, 0.97; P = 0.03; moderate certainty), which translated to 17.3 % (95 % CI 5, 26.8 %) absolute reduction in feeding intolerance. Prokinetics also reduced the risk of developing high gastric residual volumes (RR 0.69; 95 % CI 0.52, 0.91; P = 0.009; moderate quality) and increased the success of post-pyloric feeding tube placement (RR 1.60, 95 % CI 1.17, 2.21; P = 0.004; moderate quality). There was no significant improvement in the risk of vomiting, diarrhea, intensive care unit (ICU) length of stay or mortality. Prokinetic agents also did not significantly increase the rate of diarrhea. Conclusion There is moderate-quality evidence that prokinetic agents reduce feeding intolerance in critically ill patients compared to placebo or no intervention. However, the impact on other clinical outcomes such as pneumonia, mortality, and ICU length of stay is unclear. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1441-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kim Lewis
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada
| | - Zuhoor Alqahtani
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada
| | - Lauralyn Mcintyre
- Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Rm F202, Ottawa, Ontario, K1H 8L6, Canada
| | - Saleh Almenawer
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada.,Department of Surgery, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 15551, Al-Ain, United Arab Emirates
| | - Andrew Rhodes
- Department of Intensive Care Medicine, St George's Hospital, Blackshaw Road, London, SW170QT, UK
| | - Laura Evans
- Department of Medicine, Division of Pulmonary Medicine and Critical Care, New York University, 550 First Avenue, New York City, NY, 10016, USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 4200 Fifth Ave, Pittsburgh, Pennsylvania, 15260, USA
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada. .,Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, L8S 4L8, Canada. .,Department of Medicine, Division of Critical Care, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Avenue, Hamilton, Ontario, L8N 4A6, Canada.
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Refractory Hypoxemia and Use of Rescue Strategies. A U.S. National Survey of Adult Intensivists. Ann Am Thorac Soc 2016; 13:1105-14. [DOI: 10.1513/annalsats.201508-560oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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A randomised controlled feasibility and proof-of-concept trial in delayed gastric emptying when metoclopramide fails: We should revisit nasointestinal feeding versus dual prokinetic treatment: Achieving goal nutrition in critical illness and delayed gastric emptying: Trial of nasointestinal feeding versus nasogastric feeding plus prokinetics. Clin Nutr ESPEN 2016; 14:1-8. [PMID: 28531392 DOI: 10.1016/j.clnesp.2016.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 04/06/2016] [Accepted: 04/08/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Delayed gastric emptying (DGE) commonly limits the use of enteral nutrition (EN) and may increase ventilator-associated pneumonia. Nasointestinal feeding has not been tested against dual prokinetic treatment (Metoclopramide and Erythromycin) in DGE refractory to metoclopramide. This trial tests the feasibility of recruiting this 'treatment-failed' population and the proof of concept that nasointestinal (NI) feeding can increase the amount of feed tolerated (% goal) when compared to nasogastric (NG) feeding plus metoclopramide and erythromycin treatment. METHODS Eligible patients were those who were mechanically ventilated and over 20 years old, with delayed gastric emptying (DGE), defined as a gastric residual volume ≥250 ml or vomiting, and who failed to respond to first-line prokinetic treatment of 3 doses of 10 mg IV metoclopramide over 24 h. When assent was obtained, patients were randomised to receive immediate nasointestinal tube placement and feeding or nasogastric feeding plus metoclopramide and erythromycin (prokinetic) treatment. RESULTS Of 208 patients with DGE, 77 were eligible, 2 refused assent, 25 had contraindications to intervention, almost exclusively prokinetic treatment, and it was feasible to recruit 50. Compared to patients receiving prokinetics (n = 25) those randomised to nasointestinal feeding (n = 25) tolerated more of their feed goal over 5 days (87-95% vs 50-89%) and had a greater area under the curve (median [IQR] 432 [253-464]% vs 350 [213-381]%, p = 0.026) demonstrating proof of concept. However, nasointestinally fed patients also had a larger gastric loss (not feed) associated with the NI route but not with the fluid volume or energy delivered. CONCLUSIONS This is first study showing that in DGE refractory to metoclopramide NI feeding can increase the feed goal tolerated when compared to dual prokinetic treatment. Future studies should investigate the effect on clinical outcomes. EU CLINICAL TRIALS REGISTER EudraCT number: 2012-001374-29.
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Hurley JC. Impact of selective digestive decontamination on respiratory tract Candida among patients with suspected ventilator-associated pneumonia. A meta-analysis. Eur J Clin Microbiol Infect Dis 2016; 35:1121-35. [PMID: 27116009 DOI: 10.1007/s10096-016-2643-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/29/2016] [Indexed: 12/18/2022]
Abstract
The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.
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Affiliation(s)
- J C Hurley
- Department of Rural Health, Melbourne Medical School, University of Melbourne, Parkville, Australia. .,Internal Medicine Service Ballarat Health Services, PO Box 577, Ballarat, Australia, 3353. .,Infection Control Committees, St John of God Hospital and Ballarat Health Services, Ballarat, Victoria, Australia.
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Abstract
Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.
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Anand S, Jayakumar D, Aronow WS, Chandy D. Role of extracorporeal membrane oxygenation in adult respiratory failure: an overview. Hosp Pract (1995) 2016; 44:76-85. [PMID: 26848884 DOI: 10.1080/21548331.2016.1151325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides complete or partial support of the heart and lungs. Ever since its inception in the 1960s, it has been used across all age groups in the management of refractory respiratory failure and cardiogenic shock. While it has gained widespread acceptance in the neonatal and pediatric physician community, ECMO remains a controversial therapy for Acute Respiratory Distress Syndrome (ARDS) in adults. Its popularity was revived during the swine flu (H1N1) pandemic and advancements in technology have contributed to its increasing usage. ARDS continues to be a potentially devastating condition with significant mortality rates. Despite gaining more insights into this entity over the years, mechanical ventilation remains the only life-saving, yet potentially harmful intervention available for ARDS. ECMO shows promise in this regard by offering less dependence on mechanical ventilation, thereby potentially reducing ventilator-induced injury. However, the lack of rigorous clinical data has prevented ECMO from becoming the standard of care in the management of ARDS. Therefore, the results of two large ongoing randomized trials, which will hopefully throw more light on the role of ECMO in the management of this disease entity, are keenly awaited. In this article we will provide a basic overview of the development of ECMO, the types of ECMO, the pathogenesis of ARDS, different ventilation strategies for ARDS, the role of ECMO in ARDS and the role of ECMO as a bridge to lung transplantation.
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Affiliation(s)
- Suneesh Anand
- a Division of Pulmonary, Critical Care and Sleep Medicine , New York Medical College , Valhalla , NY , USA
| | - Divya Jayakumar
- b Department of Medicine , New York Medical College , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Department of Medicine , New York Medical College , Valhalla , NY , USA.,c Division of Cardiology , New York Medical College , Valhalla , NY , USA
| | - Dipak Chandy
- a Division of Pulmonary, Critical Care and Sleep Medicine , New York Medical College , Valhalla , NY , USA
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Toh Yoon E, Nishihara K, Murata H. Maintaining Enteral Nutrition in the Severely Ill using a Newly Developed Nasojejunal Feeding Tube with Gastric Decompression Function. Intern Med 2016; 55:2945-2950. [PMID: 27746430 PMCID: PMC5109560 DOI: 10.2169/internalmedicine.55.6915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
For nutritional support of critically ill patients, the enteral route is preferred over the parenteral route. Although nasojejunal feeding can be superior to gastric feeding when gastrointestinal symptoms occur, it does not necessarily solve the problem of large gastric residual volumes. We report the successful use of a newly developed nasojejunal feeding tube with gastric decompression function in an 84-year-old man with severe pneumonia. After gastric feeding was considered not well tolerated, the use of this tube improved the delivery of nutrition until the patient was stable enough to undergo percutaneous endoscopic gastrostomy.
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Affiliation(s)
- Ezekiel Toh Yoon
- Department of Internal Medicine, Hiroshima Kyoritsu Hospital, Japan
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. RECENT FINDINGS Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. SUMMARY Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.
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Wang D, Zheng SQ, Chen XC, Jiang SW, Chen HB. Comparisons between small intestinal and gastric feeding in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials. J Neurosurg 2015; 123:1194-201. [PMID: 26024007 DOI: 10.3171/2014.11.jns141109] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT Nutritional support is highly recommended for reducing the risk of nosocomial infections, such as pneumonitis, in patients with severe traumatic brain injury (TBI). Currently, there is no consensus for the preferred route of feeding. The authors compared the risks of pneumonitis and other important outcomes associated with small intestinal and gastric feeding in patients with severe TBI. METHODS This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant randomized controlled trials (up to December 16, 2013) that compared small bowel to gastric feeding in patients with severe TBI were identified from searches in the PubMed and Embase databases. The primary outcome was risk of pneumonia. Secondary outcomes included ventilator-associated pneumonia, mortality, length of intensive care unit stay, length of hospital stay, duration of mechanical ventilation, total number of complications, aspiration, diarrhea, distention, Glasgow Coma Scale score, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II score. RESULTS Five randomized controlled trials with 325 participants in total were included in the meta-analysis. Compared with gastric feeding, small bowel feeding was associated with a significant reduction in the incidence of pneumonitis (risk ratio [RR] 0.67; 95% CI 0.52-0.87; p=0.002; I2=0.0%) and ventilator-associated pneumonia (RR 0.52; 95% CI 0.34-0.81; p=0.003; I2=0.0%). Small intestinal feeding was also associated with a decrease in the total number of complications (RR 0.43; 95% CI 0.20-0.93; p=0.03; I2=68%). However, small intestinal feeding did not seem to significantly convert any of the other end points in the meta-analysis. CONCLUSIONS The limited evidence suggests that small bowel feeding in patients with severe TBI is associated with a risk of pneumonia that is lower than that with gastric feeding. From this result, the authors recommend the use of small intestinal feeding to reduce the incidence of pneumonitis in patients with severe TBI.
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Affiliation(s)
- Dong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College
- Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and
| | - Shao-Qin Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College
| | - Xian-Cai Chen
- Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and
| | - Shi-Wen Jiang
- Department of Biomedical Science, Mercer University School of Medicine, Savannah, Georgia
| | - Hai-Bin Chen
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College
- Department of Histology and Embryology, Shantou University Medical College, Shantou, Guangdong, China; and
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Stankorb SM, Ramsey C, Clark H, Osgood T. Provision of nutrition support therapies in the recent Iraq and Afghanistan conflicts. Nutr Clin Pract 2015; 29:605-11. [PMID: 25606636 DOI: 10.1177/0884533614543329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This article describes the experience of nutrition support practitioners, specifically dietitians, providing care to combat casualties. It provides a brief overview of dietitians' induction into armed service but focuses primarily on their role in providing nutrition support during the most recent conflicts in Iraq and Afghanistan. The current system of combat casualty care is discussed with specific emphasis on providing early and adequate nutrition support to U.S. combat casualties from injury, care in theater combat support hospitals (CSHs)/expeditionary medical support (EMEDs), and en route care during critical care air transport (CCAT) up to arrival at treatment facilities in the United States. The article also examines practices and challenges faced in the CSHs/EMEDs providing nutrition support to non-U.S. or coalition patients. Over the past decade in armed conflicts, dietitians, physicians, nurses, and other medical professionals have risen to challenges, have implemented systems, and continue working to optimize treatment across the spectrum of combat casualty care.
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Affiliation(s)
- Susan M Stankorb
- Brooke Army Medical Center, 4254 Hilton Head St, San Antonio, TX 78217, USA.
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Li Z, Qi J, Zhao X, Lin Y, Zhao S, Zhang Z, Li X, Kissoon N. Risk-Benefit Profile of Gastric vs Transpyloric Feeding in Mechanically Ventilated Patients. Nutr Clin Pract 2015; 31:91-8. [PMID: 26260278 DOI: 10.1177/0884533615595593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Zhuo Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Jirong Qi
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaoke Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Yiqun Lin
- University of Calgary, Calgary, Alberta, Canada
| | - Shaodong Zhao
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Zendi Zhang
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Xiaonan Li
- Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Niranjan Kissoon
- The University of British Columbia and BC Children’s Hospital, Vancouver, British Columbia, Canada
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Alkhawaja S, Martin C, Butler RJ, Gwadry‐Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD008875. [PMID: 26241698 PMCID: PMC6516803 DOI: 10.1002/14651858.cd008875.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed. OBJECTIVES To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding. SEARCH METHODS We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data. MAIN RESULTS We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials. AUTHORS' CONCLUSIONS We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.
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Affiliation(s)
- Sana Alkhawaja
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Claudio Martin
- University of Western Ontario, London Health Science CentreDepartment of Critical Care MedicineDivision of Critical Care MedicineLondon, OntarioCanadaN6J 2X7
| | - Ronald J Butler
- University of Western Ontario, London Health Sciences Centre, University HospitalDepartment of Anesthesia and Critical Care339 Windermere RdLondon, OntarioCanadaN6A 5A5
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Kulkarni AP. Proximal or distal? That is the question! Indian J Crit Care Med 2015; 19:65-6. [PMID: 25722544 PMCID: PMC4339904 DOI: 10.4103/0972-5229.151005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Atul P Kulkarni
- Department of Anaesthesiology, Division of Critical Care Medicine, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Hu B, Ye H, Sun C, Zhang Y, Lao Z, Wu F, Liu Z, Huang L, Qu C, Xian L, Wu H, Jiao Y, Liu J, Cai J, Chen W, Nie Z, Liu Z, Chen C. Metoclopramide or domperidone improves post-pyloric placement of spiral nasojejunal tubes in critically ill patients: a prospective, multicenter, open-label, randomized, controlled clinical trial. Crit Care 2015; 19:61. [PMID: 25880172 PMCID: PMC4367875 DOI: 10.1186/s13054-015-0784-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/03/2015] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION The use of prokinetic agents on post-pyloric placement of spiral nasojejunal tubes is controversial. The aim of the present study was to examine if metoclopramide or domperidone can increase the success rate of post-pyloric placement of spiral nasojejunal tubes. METHODS A multicenter, open-label, randomized, controlled trial was conducted in seven hospitals in China between April 2012 and February 2014. Patients admitted to the intensive care unit and requiring enteral nutrition for more than three days were randomly assigned to the metoclopramide, domperidone or control groups (1:1:1 ratio). The primary outcome was defined as the success rate of post-pyloric placement of spiral nasojejunal tubes, assessed 24 hours after initial placement. Secondary outcomes included success rate of post-D1, post-D2, post-D3 and proximal jejunum placement and tube migration distance. Safety of the study drugs and the tubes during the entire study period were recorded. RESULTS In total, 307 patients were allocated to the metoclopramide (n = 103), domperidone (n = 100) or control group (n = 104). The success rate of post-pyloric placement after 24 hours in the metoclopramide, domperidone and control groups was 55.0%, 51.5% and 27.3%, respectively (P = 0.0001). Logistic regression analysis identified the use of prokinetic agents, Acute Physiology and Chronic Health Evaluation (APACHE) II score <20, Sequential Organ Failure Assessment (SOFA) score <12 and without vasopressor as independent factors influencing the success rate of post-pyloric placement. No serious drug-related adverse reaction was observed. CONCLUSIONS Prokinetic agents, such as metoclopramide or domperidone, are effective at improving the success rate of post-pyloric placement of spiral nasojejunal tubes in critically ill patients. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-TRC-12001956 . Registered 21 February 2012.
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Affiliation(s)
- Bei Hu
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Heng Ye
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Yichen Zhang
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Zhigang Lao
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglinxia Road, Guangzhou, 510080, Guangdong, PR China.
| | - Fanghong Wu
- Department of Critical Care Medicine, Jiangmen Wuyi Traditional Chinese Medicine Hospital, 30 Huayuandong Road, Jiangmen, 529000, Guangdong, PR China.
| | - Zhaohui Liu
- Department of Critical Care Medicine, Guangdong Armed Police Hospital, 106 Yanling Road, Guangzhou, 510507, Guangdong, PR China.
| | - Linxi Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Shantou University Medical Collage, 57 Changping Road, Shantou, 515041, Guangdong, PR China.
| | - Changchun Qu
- Department of Critical Care Medicine, Guangdong Yunfu People's Hosipital, 120 Huanshidong Road, Yunfu, 527300, Guangdong, PR China.
| | - Lewu Xian
- Department of Critical Care Medicine, Cancer Center of Guangzhou Medical University, 78 Hengzhigang Road, Guangzhou, 510095, Guangdong, PR China.
| | - Hao Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangdong Pharmaceutical University, 19 Nonglinxia Road, Guangzhou, 510080, Guangdong, PR China.
| | - Yingjie Jiao
- Department of Critical Care Medicine, Jiangmen Wuyi Traditional Chinese Medicine Hospital, 30 Huayuandong Road, Jiangmen, 529000, Guangdong, PR China.
| | - Junling Liu
- Department of Critical Care Medicine, Guangdong Armed Police Hospital, 106 Yanling Road, Guangzhou, 510507, Guangdong, PR China.
| | - Juyu Cai
- Department of Critical Care Medicine, The First Affiliated Hospital of Shantou University Medical Collage, 57 Changping Road, Shantou, 515041, Guangdong, PR China.
| | - Weiying Chen
- Department of Critical Care Medicine, Guangdong Yunfu People's Hosipital, 120 Huanshidong Road, Yunfu, 527300, Guangdong, PR China.
| | - Zhiqiang Nie
- Department of Cardiovascular Epidemiology, Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Zaiyi Liu
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
| | - Chunbo Chen
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong, PR China.
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Hurley JC. Ventilator-associated pneumonia prevention methods using topical antibiotics: herd protection or herd peril? Chest 2014; 146:890-898. [PMID: 25287997 DOI: 10.1378/chest.13-2926] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) develops in approximately 20% of patients in the ICU receiving prolonged mechanical ventilation (MV). Among the range of methods for preventing VAP, the evidence base for topical antibiotics (TAs), including selective digestive decontamination, appears to be the most compelling. However, several observations are puzzling, and the contextual influence resulting from concurrent use of both topical placebo and TA within an ICU remains untested. As with herd protection conferred by vaccination, contextual influences resulting from a population-based intervention cannot be estimated at the level of a single trial. Estimating contextual effects requires multilevel random-effects methods. In this way the dispersion in VAP incidence across groups from 206 studies, as cited in various-source systematic reviews, was calibrated. The benchmark mean VAP incidence derived from 49 observational groups of patients receiving MV is 23.7% (95% CI, 20.6%-27.2%). In contrast, for 20 and 15 concurrent control groups from the TA evidence base that did vs did not receive topical placebo, respectively, this incidence is 38% (95% CI, 29%-48%) and 33% (95% CI, 20%-50%). This contextual influence remains significant in a meta-regression model adjusted for group-level variables, such as within a trauma ICU context. The mean VAP incidence for five other categories of control groups from the broader evidence base is within four percentage points of the benchmark. The contextual effect of TA is paradoxic, peculiar, potent, perfidious, and potentially perilous. The TA evidence base requires reappraisal to consider this herd peril.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne; Infection Control Committees, St. John of God Hospital and Ballarat Health Services, and Division of Internal Medicine, Ballarat Health Services, Ballarat, VIC, Australia.
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