Cerebrospinal fluid and plasma ascorbate concentrations following subarachnoid haemorrhage

Background

Ascorbate, the biologically active form of vitamin C, is the primary neural anti-oxidant. Ascorbate concentrations have never been quantified following aneurysmal subarachnoid haemorrhage (aSAH).

Objective

To quantify plasma and cerebrospinal fluid (CSF) ascorbate concentrations in patients following SAH.

Design Setting Participants Main Outcome Measures

Cohort study in which plasma and CSF ascorbate concentrations were measured longitudinally in 12 aSAH patients admitted to a quaternary referral intensive care unit and compared to one-off samples obtained from 20 pregnant women prior to delivery in a co-located obstetric hospital. Data are median [interquartile range] or median (95 % confidence intervals).

Results

Forty-eight plasma samples were obtained from the 12 aSAH patients (eight females, age 62 [53-68] years). Eight participants with extra-ventricular drains provided 31 paired CSF-plasma samples. Single plasma and CSF samples were obtained from 20 pregnant women (age 35 [31-37] years). Initial plasma and CSF ascorbate concentrations post aSAH were less than half those in pregnant controls (plasma: aSAH: 31 [25-39] μmol/L vs. comparator: 64 [59-77] μmol/L; P < 0.001 and CSF: 116 [80-142] μmol/L vs. 252 [240-288] μmol/L; P < 0.001). Post aSAH there was a gradual reduction in the CSF:plasma ascorbate ratio from ∼4:1 to ∼1:1. Six (50 %) patients developed vasospasm and CSF ascorbate concentrations were lower in these patients (vasospasm: 61 (25, 97) vs. no vasospasm: 110 (96, 125) μmol/L; P = 0.01).

Conclusion

Post aSAH there is a marked reduction in CSF ascorbate concentration that is most prominent in those who develop vasospasm.

Study protocol for TARGET protein: The effect of augmented administration of enteral protein to critically ill adults on clinical outcomes: A cluster randomised, cross-sectional, double cross-over, clinical trial

Background

It is unknown whether increasing dietary protein to 1.2-2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this.

Objective

To describe the study protocol for the TARGET Protein trial.

Design setting and participants

TARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022.

Main outcomes measures

The primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination.

Conclusion

TARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12621001484831).

Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness

BACKGROUND

Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients.

METHODS

Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group.

RESULTS

Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25).

CONCLUSIONS

Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.

The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial

Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objective To evaluate the effects of a 'liberal' approach to targeted blood glucose range during intensive care unit (ICU) admission. Methods This mutlicenter, parallel-group, open-label, randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dL and titrated to a target range of 180 to 252 mg/dL. In the comparator group insulin was commenced at a blood glucose >180 mg/dL and titrated to a target range of 108 to 180 mg/dL. The primary outcome was incident hypoglycemia (<72 mg/dL). Secondary outcomes included glucose metrics and clinical outcomes. Main Results At least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio: 0.21 (95% CI, 0.09 to 0.49); P<0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability and less relative hypoglycaemia (P<0.001 for all comparisons). By day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference 4.6 percentage points (95%CI, -3.9 to 13.2%); P=0.29). Conclusions A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registration available at www.anzctr.org.au, ID: ACTRN12616001135404.

Protein delivery in mechanically ventilated adults in Australia and New Zealand: current practice

Objective: To quantify current protein prescription and delivery in critically ill adults in Australia and New Zealand and compare it with international guidelines. Design: Prospective, multicentre, observational study. Setting: Five intensive care units (ICUs) across Australia and New Zealand. Participants: Mechanically ventilated adults who were anticipated to receive enteral nutrition for ≥ 24 hours. Main outcome measures: Baseline demographic and nutrition data in ICU, including assessment of requirements, prescription and delivery of enteral nutrition, parenteral nutrition and protein supplementation, were collected. The primary outcome was enteral nutrition protein delivery (g/kg ideal body weight [IBW] per day). Data are reported as mean ± standard deviation or n (%). Results: 120 patients were studied (sex, 60% male; mean age, 59 ± 16 years; mean admission APACHE II score, 20 ± 8). Enteral nutrition was delivered on 88%, parenteral nutrition on 6.8%, and protein supplements on 0.3% of 1156 study days. For the 73% (88/120) of patients who had a nutritional assessment, the mean estimated protein requirements were 99 ± 22 g/day (1.46 ± 0.55 g/kg IBW per day). The mean daily protein delivery was 54 ± 23 g (0.85 ± 0.35 g/kg IBW per day) from enteral nutrition and 56 ± 23 g (0.88 ± 0.35 g/kg IBW per day) from all sources (enteral nutrition, parenteral nutrition, protein supplements). Protein delivery was ≥ 1.2 g/kg IBW per day on 29% of the total study days per patient. Conclusions: Protein delivery as a part of current usual care to critically ill adults in Australia and New Zealand remains below that recommended in international guidelines.

Frailty is not independently associated with intensive care unit length of stay: An observational study

BACKGROUND

Frailty is independently associated with morbidity and mortality in critically ill patients. However, the association between preadmission frailty and the degree of treatment received in the intensive care unit (ICU) remains unclear.

OBJECTIVE

To describe patient length of stay in an ICU and the treatments provided according to the extent of patient frailty.

METHODS

Single-centre retrospective cohort study of adult patients admitted to a tertiary ICU between January 2018 and December 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). The primary outcome was ICU length of stay stratified by CFS score (1-8). Secondary outcomes were the proportion of patients with each CFS score treated with vasoactive agents, invasive ventilation, noninvasive ventilation, renal replacement therapy, and tracheostomy. Poisson regression and competing risks regression was used to analyse associations between ICU length of stay and potential confounders.

RESULTS

The study cohort comprised 2743 patients, with CFS scores known for 2272 (83%). Length of stay in the ICU increased with each increment in the CFS up to a score of 5, beyond which it decreased with higher frailty scores. After adjusting for age, illness severity, admission type, and treatment limitation, CFS scores were not independently associated with length of stay in the ICU (P = 0.31). The proportion of patients receiving specific ICU treatments peaked at different CFS scores, being highest for vasoactive agents at CFS 5 (47%), invasive ventilation CFS 3 (51%), noninvasive ventilation CFS 6 (11%), renal replacement therapy CFS 6 (8.2%), and tracheostomy CFS 5 (2.2%). Increasing frailty was associated with increased mortality and discharge to a destination other than home.

CONCLUSIONS

The extent of frailty is not independently associated with length of stay in the ICU. The proportion of patients receiving specific ICU treatments peaked at different CFS scores.

The use of smartphone-derived location data to evaluate participation following critical illness: A pilot observational cohort study

BACKGROUND

Disability is common following critical illness, impacting the quality of life of survivors, and is difficult to measure. 'Participation' can be quantified as involvement in life outside of their home requiring movement from their home to other locations. Participation restriction is a key element of disability, and following critical illness, participation may be diminished. It may be possible to quantify this change using pre-existing smartphone data.

OBJECTIVES

The feasibility of extracting location data from smartphones of survivors of intensive care unit (ICU) admission and assessing participation, using location-based outcomes, during recovery from critical illness was evaluated.

METHODS

Fifty consecutively admitted, consenting adult survivors of non-elective admission to ICU of greater than 48-h duration were recruited to a prospective observational cohort study where they were followed up at 3 and 6 months following discharge. The feasibility of extracting location data from survivors' smartphones and creating location-derived outcomes assessing participation was investigated over three 28-d study periods: pre-ICU admission and at 3 and 6 months following discharge. The following were calculated: time spent at home; the number of destinations visited; linear distance travelled; and two 'activity spaces', a minimum convex polygon and standard deviation ellipse.

RESULTS

Results are median [interquartile range] or n (%). The number of successful extractions was 9/50 (18%), 12/39 (31%), and 13/33 (39%); the percentage of time spent at home was 61 [56-68]%, 77 [66-87]%, and 67 [58-77]% (P = 0.16); the number of destinations visited was 34 [18-64], 38 [22-63], and 65 [46-88] (P = 0.02); linear distance travelled was 367 [56-788], 251 [114-323], and 747 [326-933] km over 28 d (P = 0.02), pre-ICU admission and at 3 and 6 months following ICU discharge, respectively. Activity spaces were successfully created.

CONCLUSION

Limited smartphone ownership, missing data, and time-consuming data extraction limit current implementation of mass extraction of location data from patients' smartphones to aid prognostication or measure outcomes. The number of journeys taken and the linear distance travelled increased between 3 and 6 months, suggesting participation may improve over time.

A multicenter randomized clinical trial of pharmacological vitamin B1 administration to critically ill patients who develop hypophosphatemia during enteral nutrition (The THIAMINE 4 HYPOPHOSPHATEMIA trial)

BACKGROUND

Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group.

METHOD

This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified.

RESULTS

Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L; P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days; P = 0.37, and deaths 9 (21 %) vs. 5 (11 %); P = 0.25).

CONCLUSIONS

In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).

The impact of bereavement support on psychological distress in family members: a systematic review and meta-analysis

Background: Persistent psychological distress occurs frequently in family members of patients who die in an intensive care unit (ICU). Objective: To determine the effectiveness of bereavement interventions in reducing persisting psychological distress in bereaved family members after death in an adult ICU. Design: Systematic review and meta-analysis of studies that assessed the effect of bereavement interventions on persisting psychological distress in bereaved family members of ICU patients. Data sources: MEDLINE and APA PsycInfo databases were searched until April 2020. Review methods: Two of us independently screened titles and abstracts of identified studies, and then completed full text evaluation of selected studies. We assessed risk of bias using version 2 of the Cochrane risk-of-bias tool for randomised trials and the Newcastle-Ottawa Scale, which is designed to assess the quality of non-randomised studies in meta-analyses. We also used random effects meta-analysis to assess the effect of various interventions on total Hospital Anxiety and Depression Scale (HADS) scores. Results: From 664 citations, five studies were included - three multicentre randomised clinical trials and two single centre observational studies. Three studies tested the intervention of written bereavement support materials and two studies used narration of family members' experiences in the ICU. All studies reported HADS scores. Scores for Impact of Event Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief were measured in some but not all studies. There was no effect of an intervention on HADS scores (weighted mean difference, -0.79 [95% confidence interval, -3.81 to 2.23]; I2 = 65.8%). Conclusions: Owing to limited data, and clinical and statistical heterogeneity, there is considerable uncertainty regarding whether bereavement support strategies reduce, increase or have no effect on psychological distress in bereaved family members.

Long-term outcomes of patients admitted to an intensive care unit with intentional self-harm

Self-harm is one of the most common reasons for admission to an intensive care unit (ICU). While most patients with self-harm survive the ICU admission, little is known about their outcomes after hospital discharge. We conducted a retrospective cohort study of patients in the Barwon region in Victoria admitted to the ICU with self-harm (between 1998 and 2018) who survived to hospital discharge. The primary objective was to determine mortality after hospital discharge, and secondarily estimate relative survival, years of potential life lost, cause of death and factors associated with death. Over the 20-year study period, there were 710 patients in the cohort. The median patient age was 37 years (interquartile range (IQR) 26-48 years). A total of 406 (57%) were female, and 527 (74%) had a prior psychiatric diagnosis. The incidence of ICU admission increased over time (incidence rate ratio 1.05; 95% confidence interval (CI) 1.03-1.06 per annum). There were 105 (15%) patients who died after hospital discharge. Relative survival decreased each year after discharge, with the greatest decrement during the first 12 months. At ten years, relative survival was 0.85 (95% CI 0.81-0.88). The median years of potential life lost was 35 (IQR 22-45). Cause of death was self-harm in 27%, possible self-harm in 32% and medical disease in 41%. The only factors associated with mortality were male sex, older age and re-admission to ICU with self-harm. Further population studies are required to confirm these findings, and to understand what interventions may improve long-term survival in this relatively young group of critically ill patients.

Urinary and renal oxygenation during dexmedetomidine infusion in critically ill adults with mechanistic insights from an ovine model

PURPOSE

Examine effects of dexmedetomidine on bladder urinary oxygen tension (PuO₂) in critically ill patients and delineate mechanisms in an ovine model.

MATERIALS AND METHODS

In 12 critically ill patients: oxygen-sensing probe inserted in the bladder catheter and dexmedetomidine infusion at a mean (SD) rate of 0.9 ± 0.3 μg/kg/h for 24-h. In 9 sheep: implantation of flow probes around the renal and pulmonary arteries, and oxygen-sensing probes in the renal cortex, renal medulla and bladder catheter; dexmedetomidine infusion at 0.5 μg/kg/h for 4-h and 1.0 μg/kg/h for 4-h then 16 h observation.

RESULTS

In patients, dexmedetomidine decreased bladder PuO₂at 2 (-Δ11 (95% CI 7-16)mmHg), 8 (-Δ 7 (0.1-13)mmHg) and 24 h (-Δ 11 (0.4-21)mmHg). In sheep, dexmedetomidine at 1 μg/kg/h reduced renal medullary oxygenation (-Δ 19 (14-24)mmHg) and bladder PuO₂ (-Δ 12 (7-17)mmHg). There was moderate correlation between renal medullary oxygenation and bladder PuO₂; intraclass correlation co-efficient 0.59 (0.34-0.80). Reductions in renal medullary oxygenation were associated with reductions in blood pressure, cardiac output and renal blood flow (P < 0.01).

CONCLUSIONS

Dexmedetomidine decreases PuO₂in critically ill patients and in sheep. In sheep this reflects a decrease in renal medullary oxygenation, associated with reductions in cardiac output, blood pressure and renal blood flow.

Use of a High-Protein Enteral Nutrition Formula to Increase Protein Delivery to Critically Ill Patients: A Randomized, Blinded, Parallel-Group, Feasibility Trial

BACKGROUND

International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice.

METHODS

We conducted a prospective, randomized, blinded, parallel-group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range).

RESULTS

The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high-protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38-0.69] g/kg/d protein), with no difference in energy delivery (difference, -26 [95% CI, -190 to 137] kcal/kg/d). There were no between-group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90-day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, -1.3% [95% CI, -17.7% to 15.0%]).

CONCLUSION

Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline-recommended levels with doses similar to usual care during critical illness.

Outcomes following grade V subarachnoid haemorrhage: A single-centre retrospective study

SummaryGrade V subarachnoid haemorrhage is associated with high mortality and morbidity, yet there are few contemporary reports on the treatment provided and outcomes of these patients. In this single-centre retrospective cohort study, we primarily sought to determine the 12-month mortality of patients admitted to the Royal Adelaide Hospital intensive care unit between 2006 and 2016 with grade V subarachnoid haemorrhage. Secondary objectives were to describe treatments provided, patient destination following hospital discharge, organ donation and hospital financial costs. Over the 11-year study period, there were 139 patients admitted with grade V subarachnoid haemorrhage. The annual number of admissions did not change over time. The median age was 56 (interquartile range 48-70) years, 88 (63%) were female and 77 (55%) had a procedure to isolate an aneurysm. There were 77 (55%) patients who died in the intensive care unit, 87 (63%) died in hospital and 89 (64%) had died at 12 months. Of the 52 patients who survived to hospital discharge, 33 (63%) were transferred to a rehabilitation facility, 17 (33%) to another acute care hospital and two (4%) were discharged. Of the 87 patients who died in hospital, 45 (52%) donated organs. The total hospital cost of managing this cohort was A$8.3 million, with a median cost of A$41,824 (interquartile range A$9,933-A$97,332) per patient. Grade V subarachnoid haemorrhage has a high mortality rate, with one-third of patients alive after one year.

Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial

BACKGROUND

Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes.

OBJECTIVE

To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L).

MAIN OUTCOME MEASURES

The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes.

RESULTS AND CONCLUSION

The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised.

TRIAL REGISTRATION

This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial

BACKGROUND: Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes. OBJECTIVE: To detail the protocol, analysis and reporting plans for a randomised clinical trial — the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial — which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0–14.0 mmol/L) or usual care (target 6.0–10.0 mmol/L). MAIN OUTCOME MEASURES: The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes. RESULTS AND CONCLUSION: The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised. TRIAL REGISTRATION: This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Obstetric admissions to intensive care units in Australia and New Zealand: a registry-based cohort study

OBJECTIVE

Describe the epidemiology of obstetric patients admitted to an Intensive Care Unit (ICU).

DESIGN

Registry-based cohort study.

SETTING

One hundred and eighty-three ICUs in Australia and New Zealand.

POPULATION

Women aged 15-49 years, admitted to ICU between 2008 and 2017, classified as pregnant, postpartum or with an obstetric-related diagnosis.

METHODS

Data were extracted from the Australia and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and national agencies.

MAIN OUTCOME MEASURES

Incidence of ICU admission, cohort characteristics, maternal outcomes and changes over time.

RESULTS

The cohort comprised 16 063 patients. The annual number of obstetric ICU admissions increased, whereas their proportion of total ICU admissions (1.3%) did not change (odds ratio 1.02, 95% CI 0.99-1.04, P = 0.14). There were 10 518 (65%) with an obstetric-related ICU diagnosis, and 5545 (35%) with a non-obstetric ICU diagnosis. Mean (SD) age was 31 (6.4) years, 1463 (9.1%) were Indigenous, 2305 (14%) were transferred from another hospital, and 3008 (19%) received mechanical ventilation. Median [IQR] length of stay in hospital was 5.2 [3.1-7.9] days, which included 1.1 [0.7-1.8] days in ICU. There were 108 (0.7%) maternal deaths, most (n = 97, 90%) having a non-obstetric diagnosis. There was no change in risk-adjusted length of stay or mortality over time.

CONCLUSIONS

Obstetric patients account for a stable proportion of ICU admissions in Australia and New Zealand. These patients typically have a short length of ICU stay and low hospital mortality.

TWEETABLE ABSTRACT

Obstetric patients in Australia/New Zealand ICUs have a short length of ICU stay and low mortality.

Incident Diabetes in Survivors of Critical Illness and Mechanisms Underlying Persistent Glucose Intolerance: A Prospective Cohort Study

OBJECTIVES

Stress hyperglycemia occurs in critically ill patients and may be a risk factor for subsequent diabetes. The aims of this study were to determine incident diabetes and prevalent prediabetes in survivors of critical illness experiencing stress hyperglycemia and to explore underlying mechanisms.

DESIGN

This was a prospective, single center, cohort study. At admission to ICU, hemoglobin A1c was measured in eligible patients. Participants returned at 3 and 12 months after ICU admission and underwent hemoglobin A1c testing and an oral glucose tolerance test. Blood was also collected for hormone concentrations, whereas gastric emptying was measured via an isotope breath test. β-cell function was modeled using standard techniques.

SETTING

Tertiary-referral, mixed medical-surgical ICU.

PATIENTS

Consecutively admitted patients who developed stress hyperglycemia and survived to hospital discharge were eligible.

MEASUREMENTS AND MAIN RESULTS

Consent was obtained from 40 patients (mean age, 58 yr [SD, 10], hemoglobin A1c 36.8 mmol/mol [4.9 mmol/mol]) with 35 attending the 3-month and 26 the 12-month visits. At 3 months, 13 (37%) had diabetes and 15 (43%) had prediabetes. At 12 months, seven (27%) participants had diabetes, whereas 11 (42%) had prediabetes. Mean hemoglobin A1c increased from baseline during the study: +0.7 mmol/mol (-1.2 to 2.5 mmol/mol) at 3 months and +3.3 mmol/mol (0.98-5.59 mmol/mol) at 12 months (p = 0.02). Gastric emptying was not significantly different across groups at either 3 or 12 months.

CONCLUSIONS

Diabetes and prediabetes occur frequently in survivors of ICU experiencing stress hyperglycemia. Based on the occurrence rate observed in this cohort, structured screening and intervention programs appear warranted.

Opinions and practices of blood glucose control in critically ill patients with pre-existing type 2 diabetes in Australian and New Zealand intensive care units

BACKGROUND

Approximately 9000 patients with type-2 diabetes mellitus (T2DM) are admitted to an intensive care unit (ICU) in Australia and New Zealand annually. For these patients, recent exploratory data suggest that targeting a more liberal blood glucose range during ICU admission may be safe and potentially beneficial. However, the current approach to blood glucose management of patients with T2DM in Australia and New Zealand ICUs is not well described, and there is uncertainty about clinician equipoise for trials of liberal glycaemic control in these patients.

AIM

The aim is to describe self-reported blood glucose management in patients with T2DM by intensivists working in Australian and New Zealand ICUs and to establish whether equipoise exists for a trial of liberal versus standard glycaemic control in such patients.

METHOD

An online questionnaire of Australia and New Zealand intensivists conducted in July-September 2016.

RESULTS

Seventy-one intensivists responded. Forty-five (63%) used a basic nomogram to titrate insulin. Sixty-six (93%) reported that insulin was commenced at blood glucose concentrations >10 mmol/L and titrated to achieve a blood glucose concentration between 6.0 and 10.0 mmol/L. A majority of respondents (75%) indicated that there was insufficient evidence to define optimal blood glucose targets in patients with T2DM, and 59 (83%) were prepared to enrol such patients in a clinical trial to evaluate a more liberal approach.

CONCLUSION

A majority of respondents were uncertain about the optimal blood glucose target range for patients with T2DM and would enrol such patients in a comparative trial of conventional versus liberal blood glucose control.

A Quality Control Study of the Adherence to Recommended Physiological Targets for the Management of Brain-Dead Organ Donors in South Australian Intensive Care Units

BACKGROUND

The Australian and New Zealand Intensive Care Society and the Australasian Transplant Coordinators Association provide recommendations on the physiological management of brain-dead donors.

PROBLEM STATEMENT

How often physiological targets are prescribed for brain-dead donors in Australian intensive care units (ICUs), and how well these compare to recommended targets is unknown. It is also unknown how often recommended targets are achieved, irrespective of prescribed targets.

METHODS

We performed a retrospective, observational quality control study in 81 adult (>18 years) brain-dead donors to describe how often physiological targets were prescribed, comparing these to current guidelines. We determined the proportion of observations within the recommended target range, irrespective of any prescribed target. We aimed to identify poor adherence to recommended targets to guide future quality improvement initiatives.

OUTCOMES

Seventy-four (91%) donors had at least 1 prescribed physiological target written on the ICU chart, with a median of 2 (range 2-5), and a maximum of 13 targets. Prescribed targets appeared to adhere well with recommended targets. Most recommended physiological targets were met irrespective of any prescribed target. However, one-quarter of serum sodium observations and one-third of blood glucose levels were above the recommended target.

IMPLICATIONS FOR PRACTICE

Quality improvement initiatives are required to improve the prescription of physiological targets in brain-dead donors in South Australia. Serum sodium and serum glucose targets were not met. However, this most likely reflects the need for current guidelines to be updated in line with current evidence.

Patients retrieved to intensive care via a dedicated retrieval service do not have increased hospital mortality compared with propensity-matched controls

This study was performed to estimate the effect of the retrieval process on mortality for patients admitted to a mixed adult intensive care unit (ICU) compared with propensity-matched, non-retrieved controls. Patients retrieved to the Royal Adelaide Hospital (RAH) ICU between 2011 and 2015 were propensity-score matched for age, gender, Aboriginal and Torres Strait Islander status, Acute Physiology and Chronic Health Evaluation (APACHE) III score and diagnostic group with non-retrieved ICU patients to estimate the average treatment effect of retrieval on hospital mortality. Factors associated with mortality in those retrieved were assessed by multiple logistic regression. Retrieved patients comprised 1,597 (14%) of 11,641 index ICU admissions; this group were younger, mean (standard deviation) 53 (18.5) versus 59 (17.7) years, had higher APACHE III scores, 61 (30.3) versus 56 (27.5), were more likely to be Indigenous (5.1% versus 3.7%) and to have sustained trauma (34% versus 9%). The average treatment effect for retrieval on hospital mortality, risk difference (95% confidence interval), was -0.7% (-2.8% to 1.3%), <i>P</i>=0.50. Variables independently associated with hospital mortality in those retrieved included age, APACHE III score and diagnostic category. Time from retrieval team activation to arrival with the patient, rural location, radial distance from the RAH and population size at the retrieval location were not significantly associated with mortality. The hospital mortality for retrieved patients was not significantly different when compared with propensity-matched controls. Mortality in those retrieved was associated with increasing age, APACHE III score and diagnostic category; however, was independent of time from team activation to arrival with the patient.

Haemoglobin concentration and volume of intravenous fluids in septic shock in the ARISE trial

BACKGROUND

Intravenous fluids may contribute to lower haemoglobin levels in patients with septic shock. We sought to determine the relationship between the changes in haemoglobin concentration and the volume of intravenous fluids administered during resuscitation from septic shock.

METHODS

We performed a retrospective cohort study of patients enrolled in the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial who were not transfused red blood cells (N = 1275). We determined the relationship between haemoglobin concentration, its change over time and volume of intravenous fluids administered over 6, 24 and 72 h using univariate and multivariate analysis.

RESULTS

Median (IQR) haemoglobin concentration at baseline was 133 (118-146) g/L and decreased to 115 (102-127) g/L within the first 6 h of resuscitation (P < 0.001), 110 (99-122) g/L after 24 h, and 109 (97-121) g/L after 72 h. At the corresponding time points, the cumulative volume of intravenous fluid administered was 1.3 (0.7-2.2) L, 2.9 (1.8-4.3) L and 4.6 (2.7-7.1) L. Haemoglobin concentration and its change from baseline had an independent but weak association with intravenous fluid volume at each time point (R² < 20%, P < 0.001). After adjusting for covariates, each litre of intravenous fluid administered was associated with a change in haemoglobin concentration of - 1.0 g/L (95% CI -1.5 to -0.6, P < 0.001) at 24 h and - 1.3 g/L (- 1.6 to - 0.9, P < 0.001) at 72 h.

CONCLUSIONS

Haemoglobin concentration decreases during resuscitation from septic shock, and has a significant but weak association with the volume of intravenous fluids administered.

Cerebral metabolic effects of strict versus conventional glycaemic targets following severe traumatic brain injury

Background

Optimal glycaemic targets for patients with severe traumatic brain injury remain unclear. The primary objective of this microdialysis study was to compare cerebral metabolism with strict versus conventional glycaemic control.

Methods

We performed a prospective single-centre randomised controlled within-subject crossover study of 20 adult patients admitted to an academic neurointensive care unit with severe traumatic brain injury. Patients underwent randomised, consecutive 24-h periods of strict (4–7 mmol/L; 72–126 mg/dl) and conventional (<10 mmol/L; 180 mg/dl) glycaemic control with microdialysis measurements performed hourly. The first 12 h of each study period was designated as a ‘washout’ period, with the subsequent 12 h being the period of interest.

Results

Cerebral glucose was lower during strict glycaemia than with conventional control (mean 1.05 [95% CI 0.58–1.51] mmol/L versus 1.28 [0.81–1.74] mmol/L; P = 0.03), as was lactate (3.07 [2.44–3.70] versus 3.56 [2.81–4.30]; P < 0.001). There were no significant differences in pyruvate or the lactate/pyruvate ratio between treatment phases. Strict glycaemia increased the frequency of low cerebral glucose (< 0.8 mmol/L; OR 1.91 [95% CI 1.01–3.65]; P < 0.05); however, there were no differences in the frequency of critically low glucose (< 0.2 mmol/L) or critically elevated lactate/pyruvate ratio between phases.

Conclusions

Compared with conventional glycaemic targets, strict blood glucose control was associated with lower mean levels of cerebral glucose and an increased frequency of abnormally low glucose levels. These data support conventional glycaemic targets following traumatic brain injury.

Trial registration

ISRCTN, ISRCTN19146279. Retrospectively registered on 2 May 2014.

Electronic supplementary material

The online version of this article (10.1186/s13054-017-1933-5) contains supplementary material, which is available to authorized users.

Long-term mortality of critically ill patients with diabetes who survive admission to the intensive care unit

OBJECTIVE

Long-term outcomes of critically ill patients with diabetes are unknown. Our objectives were to evaluate the effect of diabetes on both long-term survival rates and the average number of years of life lost for patients admitted to an intensive care unit who survived to hospital discharge.

DESIGN AND PARTICIPANTS

A data linkage study evaluating all adult patients in South Australia between 2004 and 2011 who survived hospitalisation that required admission to a public hospital ICU.

MAIN OUTCOME MEASURES

All patients were evaluated using hospital coding for diabetes, which was crossreferenced with registration with the Australian National Diabetes Services Scheme for a diagnosis of diabetes. This dataset was then linked to the Australian National Death Index. Longitudinal survival was assessed using Cox proportional hazards regression. Life-years lost were calculated using age- and sex-specific life-tables from the Australian Bureau of Statistics.

RESULTS

5450 patients with diabetes and 17 023 patients without diabetes were included. Crude mortality rates were 105.5 per 1000 person-years (95% CI, 101.6-109.6 per 1000 person-years) for patients with diabetes, and 67.6 per 1000 person-years (95% CI, 65.9-69.3 per 1000 personyears) for patients without diabetes. Patients with diabetes were older and had higher illness severity scores on admission to the ICU, were more likely to die after hospital discharge (unadjusted hazard ratio [HR], 1.52 [95% CI, 1.45-1.59]; adjusted HR, 1.16 [95% CI, 1.10-1.21]; P < 0.0001) and suffered a greater number of average lifeyears lost.

CONCLUSIONS

Our study indicates that crude mortality for ICU survivors with pre-existing diabetes is considerable after hospital discharge, and the risk of mortality is greater than for survivors without diabetes.

Structure and Function of the Kidney in Septic Shock. A Prospective Controlled Experimental Study

RATIONALE

It is unclear how septic shock causes acute kidney injury (AKI) and whether this is associated with histological change.

OBJECTIVES

We aimed to determine the nature and extent of changes in renal structure and function over time in an ovine model of septic shock.

METHODS

Fifteen sheep were instrumented with a renal artery flow probe and renal vein cannula. Ten were given intravenous Escherichia coli to induce septic shock, and five acted as controls. Animals were mechanically ventilated for 48 hours, while receiving protocol-guided parenteral fluids and a norepinephrine infusion to maintain mean arterial pressure. Renal biopsies were taken every 24 hours or whenever animals were oliguric for 2 hours. A renal pathologist, blinded to tissue source, systematically quantified histological appearance by light and electron microscopy for 31 prespecified structural changes.

MEASUREMENTS AND MAIN RESULTS

Sheep given E. coli developed septic shock, oliguria, increased serum creatinine, and reduced creatinine clearance (AKI), but there were no changes over time in renal blood flow between groups (P > 0.30) or over time within groups (P > 0.50). Renal oxygen consumption increased only in nonseptic animals (P = 0.01), but there was no between-group difference in renal lactate flux (P > 0.50). There was little structural disturbance in all biopsies and, although some cellular appearances changed over time, the only difference between septic and nonseptic animals was mesangial expansion on electron microscopy.

CONCLUSIONS

In an intensive care-supported model of gram-negative septic shock, early AKI was not associated with changes in renal blood flow, oxygen delivery, or histological appearance. Other mechanisms must contribute to septic AKI.

Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study

OBJECTIVES

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration.

DESIGN

Prospective randomized double-blind parallel-group study.

SETTING

University-affiliated mixed medical-surgical ICU.

PATIENTS

Mechanically ventilated critically ill patients suitable for enteral nutrition.

INTERVENTIONS

We randomly assigned patients to receive either daily IV placebo or pantoprazole.

MEASUREMENTS AND MAIN RESULTS

Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06).

CONCLUSIONS

We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.

Stress hyperglycaemia in critically ill patients and the subsequent risk of diabetes: a systematic review and meta-analysis

BACKGROUND

Hyperglycaemia occurs frequently in critically ill patients without diabetes. We conducted a systematic review and meta-analysis to evaluate whether this 'stress hyperglycaemia' identifies survivors of critical illness at increased risk of subsequently developing diabetes.

METHODS

We searched the MEDLINE and Embase databases from their inception to February 2016. We included observational studies evaluating adults admitted to the intensive care unit (ICU) who developed stress hyperglycaemia if the researchers reported incident diabetes or prediabetes diagnosed ≥3 months after hospital discharge. Two reviewers independently screened the titles and abstracts of identified studies and evaluated the full text of relevant studies. Data were extracted using pre-defined data fields, and risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled ORs with 95 % CIs for the occurrence of diabetes were calculated using a random-effects model.

RESULTS

Four cohort studies provided 2923 participants, including 698 with stress hyperglycaemia and 131 cases of newly diagnosed diabetes. Stress hyperglycaemia was associated with increased risk of incident diabetes (OR 3.48; 95 % CI 2.02-5.98; I ²  = 36.5 %). Studies differed with regard to definitions of stress hyperglycaemia, follow-up and cohorts studied.

CONCLUSIONS

Stress hyperglycaemia during ICU admission is associated with increased risk of incident diabetes. The strength of this association remains uncertain because of statistical and clinical heterogeneity among the included studies.

Prior exposure to hyperglycaemia attenuates the relationship between glycaemic variability during critical illness and mortality

OBJECTIVE

Our primary objective was to determine the impact of prior exposure to hyperglycaemia on the association between glycaemic variability during critical illness and mortality. Our secondary objectives included evaluating the relationships between prior hyperglycaemia and hyperglycaemia or hypoglycaemia during critical illness and mortality.

DESIGN AND PARTICIPANTS

A single-centre, retrospective, observational study in a tertiary intensive care unit. Patients admitted to the ICU between 1 September 2011 and 30 June 2015, with diabetes recorded using ICD-10-AM coding or a glycated haemoglobin (HbA1c) level of ≥ 6.5%, were stratified by prior hyperglycaemic level (HbA1c < 6.5%, 6.5%-8.5%, or > 8.5%).

MAIN OUTCOME MEASURES

Glycaemic variability was assessed as the blood glucose coefficient of variation during the patient's stay in the ICU. Multivariate logistic regression and marginal predictive plots were used to assess the impact of prior hyperglycaemia on the association between glycaemic metrics and mortality.

RESULTS

We studied 1569 patients with diabetes (HbA1c < 6.5%, n = 495; HbA1c 6.5%-8.5%, n = 731; and HbA1c > 8.5%, n = 343). Glycaemic variability was strongly associated with hospital mortality (P = 0.001), but this asso ciation showed a significant interaction with prior hyperglycaemia (P = 0.011), such that for patients with HbA1c > 8.5%, increasing glycaemic variability was not associated with increased mortality. Acute hyperglycaemia was strongly associated with mortality (P < 0.0001) and also showed a significant interaction with prior hyperglycaemia (P = 0.001), such that for patients with HbA1c > 8.5%, acute hyperglycaemia was not associated with mortality. Hypoglycaemia was also associated with mortality (P < 0.0001), but prior exposure to hyperglycaemia had a lesser effect on this relationship.

CONCLUSION

Prior exposure to hyperglycaemia attenuates the association between glycaemic variability and mortality in critically ill patients with diabetes.

Stress Induced Hyperglycemia and the Subsequent Risk of Type 2 Diabetes in Survivors of Critical Illness

OBJECTIVE

Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between stress induced hyperglycemia and incident diabetes in survivors of critical illness.

DESIGN

Retrospective cohort study.

SETTING

All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011.

PATIENTS

Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression.

MAIN RESULTS

Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness.

CONCLUSIONS

Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes.

Femoral-radial arterial pressure gradients in critically ill patients

OBJECTIVE

To investigate the presence and determinants of femoral-radial gradients in mean arterial pressure (MAP) in a critically ill population.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

Critically ill patients who were undergoing simultaneous monitoring of arterial pressure by radial arterial catheterisation and transpulmonary thermodilution (via femoral arterial access) in a Level 3, mixed medical-surgical intensive care unit, December 2007 to May 2008.

MAIN OUTCOME MEASURES

Level of agreement between simultaneous measurements of MAP via the femoral and radial arteries, determined by Bland-Altman analysis; haemodynamic and demographic factors associated with a MAP gradient, assessed by multiple linear regression.

RESULTS

131 observations were made in 24 patients. Mean age of patients was 56 (SD, 18) years, and mean APACHE II score was 27 (SD, 8). Overall mean bias between radial and femoral MAP measurements was 4.27 mmHg (limits of agreement, -3.41 to 11.94 mmHg). Fifteen patients (62%) had maximum MAP gradients > 5mmHg, and seven of these (29% of the total) had maximum gradients > 10 mmHg. The largest discrepancy in MAP was 18 mmHg in a patient with septic shock resistant to high-dose catecholamine infusion. Regression analysis failed to identify any statistically significant associations between patient factors and MAP gradient.

CONCLUSION

A systematic difference in MAP measured at the radial and femoral sites was demonstrated. In some critically ill patients, the femoral artery may be the preferred site for systemic arterial pressure monitoring.

Erythromycin dose of 70 mg accelerates gastric emptying as effectively as 200 mg in the critically ill

OBJECTIVE

To compare the effectiveness of 70-mg and 200-mg doses of intravenous erythromycin in improving gastric emptying in critically ill patients.

DESIGN

Gastric emptying was measured on consecutive days; day 1 (pre-treatment), day 2 (post-treatment) after an intravenous infusion of either 70 or 200 mg erythromycin or saline placebo (0.9%), in a randomized double-blind fashion.

SETTING

Mixed medical/surgical intensive care unit, tertiary referral.

PATIENTS AND PARTICIPANTS

Thirty-five randomly selected, mechanically ventilated, enterally fed critically ill patients (median APACHE II score 19 on admission).

INTERVENTIONS

On day 2 either 70 or 200 mg erythromycin or saline was administered intravenously over 20 min.

MEASUREMENTS AND RESULTS

Gastric emptying was measured using the [13C]octanoic acid breath test. The gastric emptying coefficient (GEC) and half-emptying time (t1/2) were calculated from the area under the 13CO2-recovery curve. Pre-treatment gastric emptying measurements were similar in all three patient groups. Treatment with both doses of erythromycin significantly reduced the gastric t1/2: 70 mg, 98 min (IQR 88-112); 200 mg, 86 min (75-104); vs. placebo, 122 min (102-190) (p<0.05). The GEC was higher with both doses of erythromycin: 70 mg, 3.8 (3.3-4.0); 200 mg, 4.0 (3.6-4.2); vs. placebo, 2.9 (2.5-3.7) (p<0.05). There was no difference in gastric emptying post-treatment between the two doses of erythromycin. The effect of erythromycin was greatest in patients with delayed gastric emptying.

CONCLUSIONS

Treatment with 70 and 200 mg intravenous erythromycin are equally effective in accelerating gastric emptying in the critically ill.