今日の臨床サポート

ICUルーチン

著者: 飯尾純一郎 済生会熊本病院 救急総合診療部

監修: 藤谷茂樹1) 聖マリアンナ医科大学 救急医学

監修: 安宅一晃2) 奈良県立病院機構 医療専門職教育研修センター/奈良県総合医療センター 集中治療部 

著者校正/監修レビュー済:2022/01/26
患者向け説明資料

概要・推奨   

  1. 刻一刻と治療内容が変化するICU診療において、バイタル、身体所見、各種検査、その日のin/outバランス、使用デバイス、使用薬剤などを毎日的確に把握する必要がある。
  1. ICUでのプレゼンテーション、カルテ記載はby problemではなく、by systemで行う。
  1. by systemは、①神経、②循環、③呼吸、④消化管 肝臓 栄養、⑤腎臓 電解質、⑥内分泌、⑦血液 凝固、⑧感染症、⑨予防、⑩To Doの順に行う。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
飯尾純一郎 : 特に申告事項無し[2022年]
監修:藤谷茂樹 : 研究費・助成金など(エーザイ株式会社)[2022年]
監修:安宅一晃 : 特に申告事項無し[2022年]

  1. COVID19を始めとしたARDS管理中に筋弛緩の持続投与などをすることもあるため、筋弛緩使用のガイドラインについて追記した。
  1. volume statusの評価の項目にCCM2021年の循環動態のレビューの項目を追記した。
  1. COVID19で有用性が示されたHFNCの管理について追記した。
  1. COVID19の人工呼吸器管理は長期化するため、抜管時のカフリークテストについて追記した。
  1. 体温管理、qSOFAの推奨度など2021 SSCGの内容を追記した。
  1. ストレス潰瘍予防のガイドラインが2020年度版を踏まえて改定した。

病態・疫学・診察

はじめに  
  1. ICU入院患者は、Problem list形式で、評価していくと、多くの臓器障害を伴っているため、見逃してしまう危険性が高い。そのため、システムベースで、評価とプランを系統的に立てていく必要がある。
  1. ICUに入室してくるパターンとして、一般病棟から、院内急変で、手術後、ER/一般外来から重症患者がある。新たに入室した患者の評価ではなく、少なくとも前日評価している患者をどのような手順で診ていくかを本稿では扱うことにする。

各論

朝、出勤して真っ先に確認する項目  
ベッドサイドにて(2-3分での評価):
  1. すばやく担当患者観察の状況を把握する。
  1. Eye ball (パッと見ること)
  1. 輸液ボトル、昇圧剤、ドレーン、人工呼吸器セッティング、その他どのようなデバイスが接続されているか。
  1. ABCDの評価
  1. A:気管挿管中でもチューブの深さ、閉塞の有無の確認を行う。
  1. B:人工呼吸器の設定、SpO2、呼気終末CO2濃度の値、呼吸器との同調性、聴診での左右差を確認する。
  1. C:昇圧剤とモニターの血圧、脈拍、末梢循環の確認をする。
  1. D:GCSの確認を、部門システム上で確認をする。
 
夜勤看護師とオンコール医師から:
  1. 夜間に起きたイベントはとても重要な情報であるので、部門システム上で確認をするのと同様に必ず手短でいいので情報を聞き出しておく。
  1. 例として、出血量、せん妄にて薬剤投与、SpO2の低下、利尿剤の投与などがある。
 
客観的所見のデータ収集:
  1. バイタルサイン
  1. 身体所見
  1. I/O バランス
  1. 栄養
  1. 輸液
  1. ドレーン
  1. 利尿
  1. 生体index
  1. モニター類の数値
  1. デバイス
  1. 人工呼吸器
  1. CRRT
  1. スワンガンツの数値、IABPの設定
  1. その他デバイス
  1. 検査値
  1. 薬剤
 
ICU daily progress note

毎日のICUでのcheck項目を一覧にしたプログレスノート。

出典

img1:  聖マリアンナ医科大学 藤谷茂樹先生ご提供
 
 
 
By system:
  1. Problem basedなアセスメントにすると漏れが出てくることがあるので、ICUではSystem basedにプロブレムを列挙し、それぞれに対してアセスメントとプランを立てる。
  1. また共通認識のフォーマットとしても利用可能であり、他職種、新規ローテーターでも同様の管理ができる点からSystem basedな管理が望ましい。上記に示した客観的データを元に、システムごとにアセスメントとプランを立てて方針を確認するプロセスである。
神経  
意識の評価:
  1. 意識障害の原因については他項に譲る。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
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文献 

John W Devlin, Yoanna Skrobik, Céline Gélinas, Dale M Needham, Arjen J C Slooter, Pratik P Pandharipande, Paula L Watson, Gerald L Weinhouse, Mark E Nunnally, Bram Rochwerg, Michele C Balas, Mark van den Boogaard, Karen J Bosma, Nathaniel E Brummel, Gerald Chanques, Linda Denehy, Xavier Drouot, Gilles L Fraser, Jocelyn E Harris, Aaron M Joffe, Michelle E Kho, John P Kress, Julie A Lanphere, Sharon McKinley, Karin J Neufeld, Margaret A Pisani, Jean-Francois Payen, Brenda T Pun, Kathleen A Puntillo, Richard R Riker, Bryce R H Robinson, Yahya Shehabi, Paul M Szumita, Chris Winkelman, John E Centofanti, Carrie Price, Sina Nikayin, Cheryl J Misak, Pamela D Flood, Ken Kiedrowski, Waleed Alhazzani
Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299.
Abstract/Text OBJECTIVE: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.
DESIGN: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.
METHODS: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.
RESULTS: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.
CONCLUSIONS: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

PMID 30113379
Michele C Balas, Eduard E Vasilevskis, Keith M Olsen, Kendra K Schmid, Valerie Shostrom, Marlene Z Cohen, Gregory Peitz, David E Gannon, Joseph Sisson, James Sullivan, Joseph C Stothert, Julie Lazure, Suzanne L Nuss, Randeep S Jawa, Frank Freihaut, E Wesley Ely, William J Burke
Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.
Crit Care Med. 2014 May;42(5):1024-36. doi: 10.1097/CCM.0000000000000129.
Abstract/Text OBJECTIVE: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.
DESIGN: Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012.
SETTING: Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center.
PATIENTS: Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service.
INTERVENTIONS: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle.
MEASUREMENTS AND MAIN RESULTS: For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates.
CONCLUSIONS: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

PMID 24394627
Michael J Murray, Heidi DeBlock, Brian Erstad, Anthony Gray, Judi Jacobi, Che Jordan, William McGee, Claire McManus, Maureen Meade, Sean Nix, Andrew Patterson, M Karen Sands, Richard Pino, Ann Tescher, Richard Arbour, Bram Rochwerg, Catherine Friederich Murray, Sangeeta Mehta
Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient.
Crit Care Med. 2016 Nov;44(11):2079-2103. doi: 10.1097/CCM.0000000000002027.
Abstract/Text OBJECTIVE: To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient."
DESIGN: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.
METHODS: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions.
RESULTS: The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.

PMID 27755068
David Osman, Christophe Ridel, Patrick Ray, Xavier Monnet, Nadia Anguel, Christian Richard, Jean-Louis Teboul
Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge.
Crit Care Med. 2007 Jan;35(1):64-8. doi: 10.1097/01.CCM.0000249851.94101.4F.
Abstract/Text OBJECTIVE: Values of central venous pressure of 8-12 mm Hg and of pulmonary artery occlusion pressure of 12-15 mm Hg have been proposed as volume resuscitation targets in recent international guidelines on management of severe sepsis. By analyzing a large number of volume challenges, our aim was to test the significance of the recommended target values in terms of prediction of volume responsiveness.
DESIGN: Retrospective study.
SETTING: A 24-bed medical intensive care unit.
PATIENTS: All consecutive septic patients monitored with a pulmonary artery catheter who underwent a volume challenge between 2001 and 2004.
INTERVENTION: None.
MEASUREMENTS AND MAIN RESULTS: A total of 150 volume challenges in 96 patients were reviewed. In 65 instances, the volume challenge resulted in an increase in cardiac index of > or =15% (responders). The pre-infusion central venous pressure was similar in responders and nonresponders (8 +/- 4 vs. 9 +/- 4 mm Hg). The pre-infusion pulmonary artery occlusion pressure was slightly lower in responders (10 +/- 4 vs. 11 +/- 4 mm Hg, p < .05). However, the significance of pulmonary artery occlusion pressure to predict fluid responsiveness was poor and similar to that of central venous pressure, as indicated by low values of areas under the receiver operating characteristic curves (0.58 and 0.63, respectively). A central venous pressure of <8 mm Hg and a pulmonary artery occlusion pressure of <12 mm Hg predicted volume responsiveness with a positive predictive value of only 47% and 54%, respectively. With the knowledge of a low stroke volume index (<30 mL.m), their positive predictive values were still unsatisfactory: 61% and 69%, respectively. When the combination of central venous pressure and pulmonary artery occlusion pressure was considered instead of either pressure alone, the degree of prediction of volume responsiveness was not improved.
CONCLUSION: Our study demonstrates that cardiac filling pressures are poor predictors of fluid responsiveness in septic patients. Therefore, their use as targets for volume resuscitation must be discouraged, at least after the early phase of sepsis has concluded.

PMID 17080001
F Michard, S Boussat, D Chemla, N Anguel, A Mercat, Y Lecarpentier, C Richard, M R Pinsky, J L Teboul
Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure.
Am J Respir Crit Care Med. 2000 Jul;162(1):134-8. doi: 10.1164/ajrccm.162.1.9903035.
Abstract/Text In mechanically ventilated patients with acute circulatory failure related to sepsis, we investigated whether the respiratory changes in arterial pressure could be related to the effects of volume expansion (VE) on cardiac index (CI). Forty patients instrumented with indwelling systemic and pulmonary artery catheters were studied before and after VE. Maximal and minimal values of pulse pressure (Pp(max) and Pp(min)) and systolic pressure (Ps(max) and Ps(min)) were determined over one respiratory cycle. The respiratory changes in pulse pressure (DeltaPp) were calculated as the difference between Pp(max) and Pp(min) divided by the mean of the two values and were expressed as a percentage. The respiratory changes in systolic pressure (DeltaPs) were calculated using a similar formula. The VE-induced increase in CI was >/= 15% in 16 patients (responders) and < 15% in 24 patients (nonresponders). Before VE, DeltaPp (24 +/- 9 versus 7 +/- 3%, p < 0.001) and DeltaPs (15 +/- 5 versus 6 +/- 3%, p < 0.001) were higher in responders than in nonresponders. Receiver operating characteristic (ROC) curves analysis showed that DeltaPp was a more accurate indicator of fluid responsiveness than DeltaPs. Before VE, a DeltaPp value of 13% allowed discrimination between responders and nonresponders with a sensitivity of 94% and a specificity of 96%. VE-induced changes in CI closely correlated with DeltaPp before volume expansion (r(2) = 0. 85, p < 0.001). VE decreased DeltaPp from 14 +/- 10 to 7 +/- 5% (p < 0.001) and VE-induced changes in DeltaPp correlated with VE-induced changes in CI (r(2) = 0.72, p < 0.001). It was concluded that in mechanically ventilated patients with acute circulatory failure related to sepsis, analysis of DeltaPp is a simple method for predicting and assessing the hemodynamic effects of VE, and that DeltaPp is a more reliable indicator of fluid responsiveness than DeltaPs.

PMID 10903232
Frédéric Michard
Changes in arterial pressure during mechanical ventilation.
Anesthesiology. 2005 Aug;103(2):419-28; quiz 449-5. doi: 10.1097/00000542-200508000-00026.
Abstract/Text Mechanical ventilation induces cyclic changes in vena cava blood flow, pulmonary artery blood flow, and aortic blood flow. At the bedside, respiratory changes in aortic blood flow are reflected by "swings" in blood pressure whose magnitude is highly dependent on volume status. During the past few years, many studies have demonstrated that arterial pressure variation is neither an indicator of blood volume nor a marker of cardiac preload but a predictor of fluid responsiveness. That is, these studies have demonstrated the value of this physical sign in answering one of the most common clinical questions, Can we use fluid to improve hemodynamics?, while static indicators of cardiac preload (cardiac filling pressures but also cardiac dimensions) are frequently unable to correctly answer this crucial question. The reliable analysis of respiratory changes in arterial pressure is possible in most patients undergoing surgery and in critically ill patients who are sedated and mechanically ventilated with conventional tidal volumes.

PMID 16052125
Paul E Marik, Rodrigo Cavallazzi, Tajender Vasu, Amyn Hirani
Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature.
Crit Care Med. 2009 Sep;37(9):2642-7. doi: 10.1097/CCM.0b013e3181a590da.
Abstract/Text OBJECTIVES: : A systematic review of the literature to determine the ability of dynamic changes in arterial waveform-derived variables to predict fluid responsiveness and compare these with static indices of fluid responsiveness. The assessment of a patient's intravascular volume is one of the most difficult tasks in critical care medicine. Conventional static hemodynamic variables have proven unreliable as predictors of volume responsiveness. Dynamic changes in systolic pressure, pulse pressure, and stroke volume in patients undergoing mechanical ventilation have emerged as useful techniques to assess volume responsiveness.
DATA SOURCES: : MEDLINE, EMBASE, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles.
STUDY SELECTION: : Clinical studies that evaluated the association between stroke volume variation, pulse pressure variation, and/or stroke volume variation and the change in stroke volume/cardiac index after a fluid or positive end-expiratory pressure challenge.
DATA EXTRACTION AND SYNTHESIS: : Data were abstracted on study design, study size, study setting, patient population, and the correlation coefficient and/or receiver operating characteristic between the baseline systolic pressure variation, stroke volume variation, and/or pulse pressure variation and the change in stroke index/cardiac index after a fluid challenge. When reported, the receiver operating characteristic of the central venous pressure, global end-diastolic volume index, and left ventricular end-diastolic area index were also recorded. Meta-analytic techniques were used to summarize the data. Twenty-nine studies (which enrolled 685 patients) met our inclusion criteria. Overall, 56% of patients responded to a fluid challenge. The pooled correlation coefficients between the baseline pulse pressure variation, stroke volume variation, systolic pressure variation, and the change in stroke/cardiac index were 0.78, 0.72, and 0.72, respectively. The area under the receiver operating characteristic curves were 0.94, 0.84, and 0.86, respectively, compared with 0.55 for the central venous pressure, 0.56 for the global end-diastolic volume index, and 0.64 for the left ventricular end-diastolic area index. The mean threshold values were 12.5 +/- 1.6% for the pulse pressure variation and 11.6 +/- 1.9% for the stroke volume variation. The sensitivity, specificity, and diagnostic odds ratio were 0.89, 0.88, and 59.86 for the pulse pressure variation and 0.82, 0.86, and 27.34 for the stroke volume variation, respectively.
CONCLUSIONS: : Dynamic changes of arterial waveform-derived variables during mechanical ventilation are highly accurate in predicting volume responsiveness in critically ill patients with an accuracy greater than that of traditional static indices of volume responsiveness. This technique, however, is limited to patients who receive controlled ventilation and who are not breathing spontaneously.

PMID 19602972
Steven W Thiel, Marin H Kollef, Warren Isakow
Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study.
Crit Care. 2009;13(4):R111. doi: 10.1186/cc7955. Epub 2009 Jul 8.
Abstract/Text INTRODUCTION: The assessment of volume responsiveness and the decision to administer a fluid bolus is a common dilemma facing physicians caring for critically ill patients. Static markers of cardiac preload are poor predictors of volume responsiveness, and dynamic markers are often limited by the presence of spontaneous respirations or cardiac arrhythmias. Passive leg raising (PLR) represents an endogenous volume challenge that can be used to predict fluid responsiveness.
METHODS: Medical intensive care unit (ICU) patients requiring volume expansion were eligible for enrollment. Non-invasive measurements of stroke volume (SV) were obtained before and during PLR using a transthoracic Doppler ultrasound device prior to volume expansion. Measurements were then repeated following volume challenge to classify patients as either volume responders or non-responders based on their hemodynamic response to volume expansion. The change in SV from baseline during PLR was then compared with the change in SV with volume expansion to determine the ability of PLR in conjunction with SV measurement to predict volume responsiveness.
RESULTS: A total of 102 fluid challenges in 89 patients were evaluated. In 47 of the 102 fluid challenges (46.1%), SV increased by > or =15% after volume infusion (responders). A SV increase induced by PLR of > or =15% predicted volume responsiveness with a sensitivity of 81%, specificity of 93%, positive predictive value of 91% and negative predictive value of 85%.
CONCLUSIONS: Non-invasive SV measurement and PLR can predict fluid responsiveness in a broad population of medical ICU patients. Less than 50% of ICU patients given fluid boluses were volume responsive.

PMID 19586543
Jean-Louis Vincent, Alexandre Joosten, Bernd Saugel
Hemodynamic Monitoring and Support.
Crit Care Med. 2021 Oct 1;49(10):1638-1650. doi: 10.1097/CCM.0000000000005213.
Abstract/Text
PMID 34269718
Xavier Monnet, Bernd Saugel
Could resuscitation be based on microcirculation data? We are not sure.
Intensive Care Med. 2018 Jun;44(6):950-953. doi: 10.1007/s00134-018-5180-2. Epub 2018 May 7.
Abstract/Text

PMID 29736790
Jean-Louis Vincent, Jan Bakker
Blood lactate levels in sepsis: in 8 questions.
Curr Opin Crit Care. 2021 Jun 1;27(3):298-302. doi: 10.1097/MCC.0000000000000824.
Abstract/Text PURPOSE OF REVIEW: Blood lactate concentrations are frequently measured in critically ill patients and have important prognostic value. Here, we review some key questions related to their clinical use in sepsis.
RECENT FINDINGS: Despite the metabolic hurdles, measuring lactate concentrations remains very informative in clinical practice. Although blood lactate levels change too slowly to represent the only guide to resuscitation, serial lactate levels can help to define the patient's trajectory and encourage a review of the therapeutic strategy if they remain stable or increase over time.
SUMMARY: Lactate concentrations respond too slowly to be used to guide acute changes in therapy, but can help evaluate overall response. Hyperlactatemia should not be considered as a problem in itself, but as a warning of altered cell function.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
PMID 33852499
Amir Qaseem, Itziar Etxeandia-Ikobaltzeta, Nick Fitterman, John W Williams, Devan Kansagara, Clinical Guidelines Committee of the American College of Physicians, Pelin Batur, Thomas G Cooney, Carolyn J Crandall, Lauri A Hicks, Jennifer S Lin, Michael Maroto, Jeffrey Tice, Janice E Tufte, Sandeep Vijan, John W Williams
Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians.
Ann Intern Med. 2021 Jul;174(7):977-984. doi: 10.7326/M20-7533. Epub 2021 Apr 27.
Abstract/Text DESCRIPTION: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of high-flow nasal oxygen (HFNO) in hospitalized patients for initial or postextubation management of acute respiratory failure. It is based on the best available evidence on the benefits and harms of HFNO, taken in the context of costs and patient values and preferences.
METHODS: The ACP Clinical Guidelines Committee based these recommendations on a systematic review on the efficacy and safety of HFNO. The patient-centered health outcomes evaluated included all-cause mortality, hospital length of stay, 30-day hospital readmissions, hospital-acquired pneumonia, days of intubation or reintubation, intensive care unit (ICU) admission and ICU transfers, patient comfort, dyspnea, delirium, barotrauma, compromised nutrition, gastric dysfunction, functional independence at discharge, discharge disposition, and skin breakdown. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.
TARGET AUDIENCE AND PATIENT POPULATION: The target audience is all clinicians, and the target patient population is adult patients with acute respiratory failure treated in a hospital setting (including emergency departments, hospital wards, intermediate or step-down units, and ICUs).
RECOMMENDATION 1A: ACP suggests that clinicians use high-flow nasal oxygen rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence).
RECOMMENDATION 1B: ACP suggests that clinicians use high-flow nasal oxygen rather than conventional oxygen therapy for hospitalized adults with postextubation acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence).

PMID 33900796
Dipayan Chaudhuri, David Granton, Dominic Xiang Wang, Karen E A Burns, Yigal Helviz, Sharon Einav, Vatsal Trivedi, Tommaso Mauri, Jean-Damien Ricard, Jordi Mancebo, Jean-Pierre Frat, Sameer Jog, Gonzalo Hernandez, Salvatore M Maggiore, Lawrence Mbuagbaw, Carol L Hodgson, Samir Jaber, Ewan C Goligher, Laurent Brochard, Bram Rochwerg
High-Flow Nasal Cannula in the Immediate Postoperative Period: A Systematic Review and Meta-analysis.
Chest. 2020 Nov;158(5):1934-1946. doi: 10.1016/j.chest.2020.06.038. Epub 2020 Jun 29.
Abstract/Text BACKGROUND: Studies have demonstrated that high-flow nasal cannula (HFNC) prevents intubation in acute hypoxic respiratory failure when compared with conventional oxygen therapy (COT). However, the data examining routine HFNC use in the immediate postoperative period are less clear.
RESEARCH QUESTION: Is routine HFNC use superior to COT or noninvasive ventilation (NIV) use in preventing intubation in patients postoperatively?
STUDY DESIGN AND METHODS: We comprehensively searched databases (PubMed, Embase, Web of Science) to identify randomized controlled trials (RCTs) that compared the effect of HFNC use with that of COT or NIV in the immediate postoperative period on reintubation, escalation of respiratory support, hospital mortality, ICU and hospital length of stay (LOS), postoperative hypoxemia, and treatment complications. We assessed individual study risk of bias (RoB) by using the revised Cochrane RoB 2 tool and rated certainty in outcomes by using the Grading of Recommendations Assessment, Development and Evaluation framework.
RESULTS: We included 11 RCTs enrolling 2,201 patients. Ten compared HFNC with COT and one with NIV. Compared with COT use, HFNC use in the postoperative period was associated with a lower reintubation rate (relative risk [RR], 0.32; 95% CI, 0.12-0.88; absolute risk reduction [ARR], 2.9%; moderate certainty) and decreased escalation of respiratory support (RR, 0.54; 95% CI, 0.31-0.94; ARR, 5.8%; very low certainty). Post hoc subgroup analysis suggested that this effect was driven by patients who were obese and/or at high risk (subgroup differences, P = .06). We did not find differences in any of the other stated outcomes between HFNC and COT. HFNC was also no different from NIV in reintubation rate, respiratory therapy failure, or ICU LOS.
INTERPRETATION: With evidence of moderate certainty, prophylactic HFNC reduces reintubation and escalation of respiratory support compared with COT in the immediate postoperative period after cardiothoracic surgery. This effect is likely driven by patients who are at high risk and/or obese. These findings support postoperative prophylactic HFNC use in the patients who are at high risk and/or obese undergoing cardiothoracic surgery.

Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
PMID 32615190
Christophe Guitton, Stephan Ehrmann, Christelle Volteau, Gwenhael Colin, Adel Maamar, Vanessa Jean-Michel, Pierre-Joachim Mahe, Mickael Landais, Noelle Brule, Cedric Bretonnière, Olivier Zambon, Mickael Vourc'h
Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial.
Intensive Care Med. 2019 Apr;45(4):447-458. doi: 10.1007/s00134-019-05529-w. Epub 2019 Jan 21.
Abstract/Text PURPOSE: Preoxygenation with high-flow therapy by nasal cannulae (HFNC) is now widespread in the intensive care unit (ICU). However, no large randomized study has assessed its relevance in non-severely hypoxemic patients. In a randomized controlled trial (PROTRACH study), we aimed to evaluate preoxygenation with HFNC vs. standard bag-valve mask oxygenation (SMO) in non-severely hypoxemic patients during rapid sequence intubation (RSI) in the ICU.
METHODS: Randomized controlled trial including non-severely hypoxemic patients requiring intubation in the ICU. Patients received preoxygenation by HFNC or SMO during RSI. HFNC was maintained throughout the intubation procedure whereas SMO was removed to perform laryngoscopy. The primary outcome was the lowest pulse oximetry (SpO2) throughout the intubation procedure. Secondary outcomes included drop in SpO2, adverse events related to intubation, and outcome in the ICU.
RESULTS: A total of 192 patients were randomized. In the intent-to-treat analysis, 184 patients (HFNC n = 95; SMO n = 89), the median [IQR] lowest SpO2 was 100% [97; 100] for HFNC and 99% [95; 100] for the SMO group (P = 0.30). Mild desaturation below 95% was more frequent with SMO (23%) than with HFNC (12%) (RR 0.51, 95% CI 0.26-0.99, P = 0.045). There were fewer adverse events in the HFNC group (6%) than in the SMO group (19%) (RR 0.31, 95% CI 0.13-0.76, P = 0.007), including fewer severe adverse events, respectively 6 (6%) and 14 (16%) with HFNC and SMO (RR 0.38, 95% CI 0.15-0.95, P = 0.03).
CONCLUSIONS: Compared with SMO, preoxygenation with HFNC in the ICU did not improve the lowest SpO2 during intubation in the non-severely hypoxemic patients but led to a reduction in intubation-related adverse events.
TRIAL REGISTRATION: Clinical trial Submission: 7 March 2016. Registry name: Benefits of high-flow nasal cannulae oxygen for preoxygenation during intubation in non-severely hypoxemic patients: the PROTRACH study. Clinicaltrials.gov identifier: NCT02700321. Eudra CT: 2015-A00145-44. CPP: 15/13-975 (Comité de protection des personnes de Rennes). URL registry: https://clinicaltrials.gov/ct2/show/record/NCT02700321 .

PMID 30666367
Federico Longhini, Corrado Pelaia, Eugenio Garofalo, Andrea Bruni, Roberta Placida, Caterina Iaquinta, Eugenio Arrighi, Graziella Perri, Giada Procopio, Anna Cancelliere, Serena Rovida, Giuseppina Marrazzo, Girolamo Pelaia, Paolo Navalesi
High-flow nasal cannula oxygen therapy for outpatients undergoing flexible bronchoscopy: a randomised controlled trial.
Thorax. 2021 Apr 29;. doi: 10.1136/thoraxjnl-2021-217116. Epub 2021 Apr 29.
Abstract/Text INTRODUCTION: High-flow nasal cannula (HFNC) provides benefits to patients undergoing flexible bronchoscopy (FOB). We compared the effects of HFNC versus standard therapy (ST) on gas exchange, lung volume and diaphragm function in patients undergoing FOB for bronchoalveolar lavage (BAL).
METHODS: 36 outpatients were randomised to ST or HFNC. Arterial blood gases, episodes of severe desaturation, changes of end-expiratory lung impedance (ΔEELI), diaphragm ultrasound were recorded. Measurements were done at baseline (T0), after bronchoscope insertion (T1), at the end of the procedure (T2) and 10 min afterwards (T3).
RESULTS: Arterial partial oxygen pressure (PaO2) was not different between T0 (10.8 (95% CI 8.7 to 12.0) kPa and T2 (11.1 (95% CI 10.4 to 12.0) kPa) with HFNC, while decreased from 11.1 (95% CI 10.5 to 12.1) to 9.1 (95% CI 8.4 to 9.8) kPa with ST. At T2, PaO2 was significantly higher with HFNC than with ST (p<0.001). Also, with HFNC, compared with ST, fewer desaturations occurred (11% vs 56%; p<0.01). ΔEELI was no different at the different time points with HFNC, while with ST there was a significant decrease at T1 (-170 (95% CI -382 to -32) mL, p=0.003), T2 (-211 (95% CI -425 to -148) mL, p<0.001) and T3 (-213 (95% CI -398 to -81) mL, p<0.001), as opposed to T0. EELI was lower with ST than HFNC at T1 (p=0.006), T2 (p=0.001) and T3 (p=0.002). Diaphragm displacement was no different between groups (p=0.748), while the thickening fraction significantly increased at T1 and T2 with ST only (p<0.01).
CONCLUSIONS: During FOB for BAL, HFNC improves gas exchange, avoiding loss of end-expiratory lung volume and preventing increase of diaphragm activation.
TRIAL REGISTRATION NUMBER: NCT04016480.

© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.
PMID 33927023
Timothy D Girard, Waleed Alhazzani, John P Kress, Daniel R Ouellette, Gregory A Schmidt, Jonathon D Truwit, Suzanne M Burns, Scott K Epstein, Andres Esteban, Eddy Fan, Miguel Ferrer, Gilles L Fraser, Michelle Ng Gong, Catherine L Hough, Sangeeta Mehta, Rahul Nanchal, Sheena Patel, Amy J Pawlik, William D Schweickert, Curtis N Sessler, Thomas Strøm, Kevin C Wilson, Peter E Morris, ATS/CHEST Ad Hoc Committee on Liberation from Mechanical Ventilation in Adults
An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests.
Am J Respir Crit Care Med. 2017 Jan 1;195(1):120-133. doi: 10.1164/rccm.201610-2075ST.
Abstract/Text BACKGROUND: Interventions that lead to earlier liberation from mechanical ventilation can improve patient outcomes. This guideline, a collaborative effort between the American Thoracic Society and the American College of Chest Physicians, provides evidence-based recommendations to optimize liberation from mechanical ventilation in critically ill adults.
METHODS: Two methodologists performed evidence syntheses to summarize available evidence relevant to key questions about liberation from mechanical ventilation. The methodologists appraised the certainty in the evidence (i.e., the quality of evidence) using the Grading of Recommendations, Assessment, Development, and Evaluation approach and summarized the results in evidence profiles. The guideline panel then formulated recommendations after considering the balance of desirable consequences (benefits) versus undesirable consequences (burdens, adverse effects, and costs), the certainty in the evidence, and the feasibility and acceptability of various interventions. Recommendations were rated as strong or conditional.
RESULTS: The guideline panel made four conditional recommendations related to rehabilitation protocols, ventilator liberation protocols, and cuff leak tests. The recommendations were for acutely hospitalized adults mechanically ventilated for more than 24 hours to receive protocolized rehabilitation directed toward early mobilization, be managed with a ventilator liberation protocol, be assessed with a cuff leak test if they meet extubation criteria but are deemed high risk for postextubation stridor, and be administered systemic steroids for at least 4 hours before extubation if they fail the cuff leak test.
CONCLUSIONS: The American Thoracic Society/American College of Chest Physicians recommendations are intended to support healthcare professionals in their decisions related to liberating critically ill adults from mechanical ventilation.

PMID 27762595
Stephen A McClave, Beth E Taylor, Robert G Martindale, Malissa M Warren, Debbie R Johnson, Carol Braunschweig, Mary S McCarthy, Evangelia Davanos, Todd W Rice, Gail A Cresci, Jane M Gervasio, Gordon S Sacks, Pamela R Roberts, Charlene Compher, Society of Critical Care Medicine, American Society for Parenteral and Enteral Nutrition
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211. doi: 10.1177/0148607115621863.
Abstract/Text
PMID 26773077
Joseph Boullata, Jennifer Williams, Faith Cottrell, Lauren Hudson, Charlene Compher
Accurate determination of energy needs in hospitalized patients.
J Am Diet Assoc. 2007 Mar;107(3):393-401. doi: 10.1016/j.jada.2006.12.014.
Abstract/Text OBJECTIVE: To evaluate the accuracy of seven predictive equations, including the Harris-Benedict and the Mifflin equations, against measured resting energy expenditure (REE) in hospitalized patients, including patients with obesity and critical illness.
DESIGN: A retrospective evaluation using the nutrition support service database of a patient cohort from a similar timeframe as those used to develop the Mifflin equations.
SUBJECTS/SETTING: All patients with an ordered nutrition assessment who underwent indirect calorimetry at our institution over a 1-year period were included.
INTERVENTION: Available data was applied to REE predictive equations, and results were compared to REE measurements.
MAIN OUTCOME MEASURES: Accuracy was defined as predictions within 90% to 110% of the measured REE. Differences >10% or 250 kcal from REE were considered clinically unacceptable.
STATISTICAL ANALYSES PERFORMED: Regression analysis was performed to identify variables that may predict accuracy. Limits-of-agreement analysis was carried out to describe the level of bias for each equation.
RESULTS: A total of 395 patients, mostly white (61%) and African American (36%), were included in this analysis. Mean age+/-standard deviation was 56+/-18 years (range 16 to 92 years) in this group, and mean body mass index was 24+/-5.6 (range 13 to 53). Measured REE was 1,617+/-355 kcal/day for the entire group, 1,790+/-397 kcal/day in the obese group (n=51), and 1,730+/-402 kcal/day in the critically ill group (n=141). The most accurate prediction was the Harris-Benedict equation when a factor of 1.1 was multiplied to the equation (Harris-Benedict 1.1), but only in 61% of all the patients, with significant under- and over-predictions. In the patients with obesity, the Harris-Benedict equation using actual weight was most accurate, but only in 62% of patients; and in the critically ill patients the Harris-Benedict 1.1 was most accurate, but only in 55% of patients. The bias was also lowest with Harris-Benedict 1.1 (mean error -9 kcal/day, range +403 to -421 kcal/day); but errors across all equations were clinically unacceptable.
CONCLUSIONS: No equation accurately predicted REE in most hospitalized patients. Without a reliable predictive equation, only indirect calorimetry will provide accurate assessment of energy needs. Although indirect calorimetry is considered the standard for assessing REE in hospitalized patients, several predictive equations are commonly used in practice. Their accuracy in hospitalized patients has been questioned. This study evaluated several of these equations, and found that even the most accurate equation (the Harris-Benedict 1.1) was inaccurate in 39% of patients and had an unacceptably high error. Without knowing which patient's REE is being accurately predicted, indirect calorimetry may still be necessary in difficult to manage hospitalized patients.

PMID 17324656
Vasken Artinian, Hicham Krayem, Bruno DiGiovine
Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients.
Chest. 2006 Apr;129(4):960-7. doi: 10.1378/chest.129.4.960.
Abstract/Text STUDY OBJECTIVES: To determine the impact of early enteral feeding on the outcome of critically ill medical patients.
DESIGN: Retrospective analysis of a prospectively collected large multi-institutional ICU database.
PATIENTS: A total of 4,049 patients requiring mechanical ventilation for > 2 days.
MEASUREMENTS AND RESULTS: Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing.
CONCLUSION: Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.

PMID 16608945
Annika Reintam Blaser, Joel Starkopf, Waleed Alhazzani, Mette M Berger, Michael P Casaer, Adam M Deane, Sonja Fruhwald, Michael Hiesmayr, Carole Ichai, Stephan M Jakob, Cecilia I Loudet, Manu L N G Malbrain, Juan C Montejo González, Catherine Paugam-Burtz, Martijn Poeze, Jean-Charles Preiser, Pierre Singer, Arthur R H van Zanten, Jan De Waele, Julia Wendon, Jan Wernerman, Tony Whitehouse, Alexander Wilmer, Heleen M Oudemans-van Straaten, ESICM Working Group on Gastrointestinal Function
Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.
Intensive Care Med. 2017 Mar;43(3):380-398. doi: 10.1007/s00134-016-4665-0. Epub 2017 Feb 6.
Abstract/Text PURPOSE: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.
METHODS: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.
RESULTS: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.
CONCLUSIONS: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

PMID 28168570
Bouwe P Krijthe, Jan Heeringa, Jan A Kors, Albert Hofman, Oscar H Franco, Jacqueline C M Witteman, Bruno H Stricker
Serum potassium levels and the risk of atrial fibrillation: the Rotterdam Study.
Int J Cardiol. 2013 Oct 15;168(6):5411-5. doi: 10.1016/j.ijcard.2013.08.048. Epub 2013 Aug 24.
Abstract/Text BACKGROUND: Atrial fibrillation is the most common sustained arrhythmia in the elderly. Serum potassium is associated with ventricular arrhythmias and cardiac arrest. Little is known about the association of serum potassium with atrial fibrillation. The objective of this study was to investigate the association of serum potassium and the risk of atrial fibrillation in a population based setting.
METHODS: The study was performed within the prospective population-based Rotterdam Study. The study population consisted of 4059 participants without atrial fibrillation at baseline for whom baseline levels of serum potassium were measured. Atrial fibrillation was ascertained from centre visit ECG assessments as well as medical records.
RESULTS: During a mean follow up of 11.8 years (SD=5.2 yr), 474 participants developed atrial fibrillation. Participants with hypokalemia (<3.5 mmol/l) had a higher risk of atrial fibrillation (HR: 1.63, 95%CI: 1.03-2.56) than those with normokalemia (3.5-5.0 mmol/l). This association was independent of age, sex, serum magnesium, and other potential confounders. Especially in participants with a history of myocardial infarction, those with hypokalemia had a higher risk of atrial fibrillation than those with normokalemia (HR: 3.81, 95%-CI: 1.51-9.61).
CONCLUSIONS: In this study low serum levels of potassium were associated with a higher risk of atrial fibrillation.

© 2013.
PMID 24012173
Abhinav Goyal, John A Spertus, Kensey Gosch, Lakshmi Venkitachalam, Philip G Jones, Greet Van den Berghe, Mikhail Kosiborod
Serum potassium levels and mortality in acute myocardial infarction.
JAMA. 2012 Jan 11;307(2):157-64. doi: 10.1001/jama.2011.1967.
Abstract/Text CONTEXT: Clinical practice guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients with acute myocardial infarction (AMI). These guidelines are based on small studies that associated low potassium levels with ventricular arrhythmias in the pre-β-blocker and prereperfusion era. Current studies examining the relationship between potassium levels and mortality in AMI patients are lacking.
OBJECTIVE: To determine the relationship between serum potassium levels and in-hospital mortality in AMI patients in the era of β-blocker and reperfusion therapy.
DESIGN, SETTING, AND PATIENTS: Retrospective cohort study using the Cerner Health Facts database, which included 38,689 patients with biomarker-confirmed AMI, admitted to 67 US hospitals between January 1, 2000, and December 31, 2008. All patients had in-hospital serum potassium measurements and were categorized by mean postadmission serum potassium level (<3.0, 3.0-<3.5, 3.5-<4.0, 4.0-<4.5, 4.5-<5.0, 5.0-<5.5, and ≥5.5 mEq/L). Hierarchical logistic regression was used to determine the association between potassium levels and outcomes after adjusting for patient- and hospital-level factors.
MAIN OUTCOME MEASURES: All-cause in-hospital mortality and the composite of ventricular fibrillation or cardiac arrest.
RESULTS: There was a U-shaped relationship between mean postadmission serum potassium level and in-hospital mortality that persisted after multivariable adjustment. Compared with the reference group of 3.5 to less than 4.0 mEq/L (mortality rate, 4.8%; 95% CI, 4.4%-5.2%), mortality was comparable for mean postadmission potassium of 4.0 to less than 4.5 mEq/L (5.0%; 95% CI, 4.7%-5.3%), multivariable-adjusted odds ratio (OR), 1.19 (95% CI, 1.04-1.36). Mortality was twice as great for potassium of 4.5 to less than 5.0 mEq/L (10.0%; 95% CI, 9.1%-10.9%; multivariable-adjusted OR, 1.99; 95% CI, 1.68-2.36), and even greater for higher potassium strata. Similarly, mortality rates were higher for potassium levels of less than 3.5 mEq/L. In contrast, rates of ventricular fibrillation or cardiac arrest were higher only among patients with potassium levels of less than 3.0 mEq/L and at levels of 5.0 mEq/L or greater.
CONCLUSION: Among inpatients with AMI, the lowest mortality was observed in those with postadmission serum potassium levels between 3.5 and <4.5 mEq/L compared with those who had higher or lower potassium levels.

PMID 22235086
Melanie Meersch, Christoph Schmidt, Andreas Hoffmeier, Hugo Van Aken, Carola Wempe, Joachim Gerss, Alexander Zarbock
Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial.
Intensive Care Med. 2017 Nov;43(11):1551-1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21.
Abstract/Text PURPOSE: Care bundles are recommended in patients at high risk for acute kidney injury (AKI), although they have not been proven to improve outcomes. We sought to establish the efficacy of an implementation of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines to prevent cardiac surgery-associated AKI in high risk patients defined by renal biomarkers.
METHODS: In this single-center trial, we examined the effect of a "KDIGO bundle" consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high risk patients defined as urinary [TIMP-2]·[IGFBP7] > 0.3 undergoing cardiac surgery. The primary endpoint was the rate of AKI defined by KDIGO criteria within the first 72 h after surgery. Secondary endpoints included AKI severity, need for dialysis, length of stay, and major adverse kidney events (MAKE) at days 30, 60, and 90.
RESULTS: AKI was significantly reduced with the intervention compared to controls [55.1 vs. 71.7%; ARR 16.6% (95 CI 5.5-27.9%); p = 0.004]. The implementation of the bundle resulted in significantly improved hemodynamic parameters at different time points (p < 0.05), less hyperglycemia (p < 0.001) and use of ACEi/ARBs (p < 0.001) compared to controls. Rates of moderate to severe AKI were also significantly reduced by the intervention compared to controls. There were no significant effects on other secondary outcomes.
CONCLUSION: An implementation of the KDIGO guidelines compared with standard care reduced the frequency and severity of AKI after cardiac surgery in high risk patients. Adequately powered multicenter trials are warranted to examine mortality and long-term renal outcomes.

PMID 28110412
Laurent Brochard, Fekri Abroug, Matthew Brenner, Alain F Broccard, Robert L Danner, Miquel Ferrer, Franco Laghi, Sheldon Magder, Laurent Papazian, Paolo Pelosi, Kees H Polderman, ATS/ERS/ESICM/SCCM/SRLF Ad Hoc Committee on Acute Renal Failure
An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine.
Am J Respir Crit Care Med. 2010 May 15;181(10):1128-55. doi: 10.1164/rccm.200711-1664ST.
Abstract/Text OBJECTIVES: To address the issues of Prevention and Management of Acute Renal Failure in the ICU Patient, using the format of an International Consensus Conference.
METHODS AND QUESTIONS: Five main questions formulated by scientific advisors were addressed by experts during a 2-day symposium and a Jury summarized the available evidence: (1) Identification and definition of acute kidney insufficiency (AKI), this terminology being selected by the Jury; (2) Prevention of AKI during routine ICU Care; (3) Prevention in specific diseases, including liver failure, lung Injury, cardiac surgery, tumor lysis syndrome, rhabdomyolysis and elevated intraabdominal pressure; (4) Management of AKI, including nutrition, anticoagulation, and dialysate composition; (5) Impact of renal replacement therapy on mortality and recovery.
RESULTS AND CONCLUSIONS: The Jury recommended the use of newly described definitions. AKI significantly contributes to the morbidity and mortality of critically ill patients, and adequate volume repletion is of major importance for its prevention, though correction of fluid deficit will not always prevent renal failure. Fluid resuscitation with crystalloids is effective and safe, and hyperoncotic solutions are not recommended because of their renal risk. Renal replacement therapy is a life-sustaining intervention that can provide a bridge to renal recovery; no method has proven to be superior, but careful management is essential for improving outcome.

PMID 20460549
Xiao-Mei Yang, Guo-Wei Tu, Ji-Li Zheng, Bo Shen, Guo-Guang Ma, Guang-Wei Hao, Jian Gao, Zhe Luo
A comparison of early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.
BMC Nephrol. 2017 Aug 7;18(1):264. doi: 10.1186/s12882-017-0667-6. Epub 2017 Aug 7.
Abstract/Text BACKGROUND: To investigate the impact of timing the initiation of renal replacement therapy (RRT) on clinical outcomes in critically ill patients with acute kidney injury (AKI), focusing on the randomized controlled trials (RCTs) in this field.
METHODS: The PubMed, EMBASE and Cochrane databases were searched between January 1, 1985, and June 30, 2016, to identify randomized trials that assessed the timing of initiation of RRT in patients with AKI.
RESULTS: Nine RCTs, with a total of 1636 patients, were enrolled in this meta-analysis. A pooled analysis of the studies indicated no mortality benefit with "early" RRT, with an RR of 0.98 (95% CI 0.78 to 1.23, P = 0.84). There was no significant difference in intensive care unit (ICU) length of stay (LOS) or hospital LOS between the early and late RRT groups for survivors or nonsurvivors. Pooled analysis also demonstrated no significant change in renal function recovery (RR 1.02, 95% CI 0.88 to 1.19, I2 = 59%), RRT dependence (RR 0.76, 95% CI 0.42 to 1.37, I2 = 0%), duration of RRT (Mean difference 1.43, 95% CI -1.75 to 4.61, I2 = 78%), renal recovery time (Mean difference 0.73, 95% CI -2.09 to 3.56, I2 = 70%) or mechanical ventilation time (Mean difference - 0.95, 95% CI -3.54 to 1.64, I2 = 64%) between the early and late RRT groups. We found no significant differences in complications between the groups.
CONCLUSIONS: Our meta-analysis revealed that the "early" initiation of RRT in critically ill patients did not result in reduced mortality. Pooled analysis of secondary outcomes also showed no significant difference between the early and late RRT groups. More well-designed and large-scale trials are expected to confirm the result of this meta-analysis.

PMID 28784106
Djillali Annane, Stephen M Pastores, Bram Rochwerg, Wiebke Arlt, Robert A Balk, Albertus Beishuizen, Josef Briegel, Joseph Carcillo, Mirjam Christ-Crain, Mark S Cooper, Paul E Marik, Gianfranco Umberto Meduri, Keith M Olsen, Sophia C Rodgers, James A Russell, Greet Van den Berghe
Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017.
Crit Care Med. 2017 Dec;45(12):2078-2088. doi: 10.1097/CCM.0000000000002737.
Abstract/Text OBJECTIVE: To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.
PARTICIPANTS: A multispecialty task force of 16 international experts in critical care medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.
DESIGN/METHODS: The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.
RESULTS: The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of < 9 μg/dL) after cosyntropin (250 μg) administration and a random plasma cortisol of < 10 μg/dL may be used by clinicians. We suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using IV hydrocortisone < 400 mg/day for ≥ 3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO2/FiO2 < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).
CONCLUSIONS: Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

PMID 28938253
Jeffrey L Carson, Brenda J Grossman, Steven Kleinman, Alan T Tinmouth, Marisa B Marques, Mark K Fung, John B Holcomb, Orieji Illoh, Lewis J Kaplan, Louis M Katz, Sunil V Rao, John D Roback, Aryeh Shander, Aaron A R Tobian, Robert Weinstein, Lisa Grace Swinton McLaughlin, Benjamin Djulbegovic, Clinical Transfusion Medicine Committee of the AABB
Red blood cell transfusion: a clinical practice guideline from the AABB*.
Ann Intern Med. 2012 Jul 3;157(1):49-58. doi: 10.7326/0003-4819-157-1-201206190-00429.
Abstract/Text DESCRIPTION: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.
METHODS: These guidelines are based on a systematic review of randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay. RECOMMENDATION 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence). RECOMMENDATION 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence). RECOMMENDATION 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence). RECOMMENDATION 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

PMID 22751760
Laura Evans, Andrew Rhodes, Waleed Alhazzani, Massimo Antonelli, Craig M Coopersmith, Craig French, Flávia R Machado, Lauralyn Mcintyre, Marlies Ostermann, Hallie C Prescott, Christa Schorr, Steven Simpson, W Joost Wiersinga, Fayez Alshamsi, Derek C Angus, Yaseen Arabi, Luciano Azevedo, Richard Beale, Gregory Beilman, Emilie Belley-Cote, Lisa Burry, Maurizio Cecconi, John Centofanti, Angel Coz Yataco, Jan De Waele, R Phillip Dellinger, Kent Doi, Bin Du, Elisa Estenssoro, Ricard Ferrer, Charles Gomersall, Carol Hodgson, Morten Hylander Møller, Theodore Iwashyna, Shevin Jacob, Ruth Kleinpell, Michael Klompas, Younsuck Koh, Anand Kumar, Arthur Kwizera, Suzana Lobo, Henry Masur, Steven McGloughlin, Sangeeta Mehta, Yatin Mehta, Mervyn Mer, Mark Nunnally, Simon Oczkowski, Tiffany Osborn, Elizabeth Papathanassoglou, Anders Perner, Michael Puskarich, Jason Roberts, William Schweickert, Maureen Seckel, Jonathan Sevransky, Charles L Sprung, Tobias Welte, Janice Zimmerman, Mitchell Levy
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.
Crit Care Med. 2021 Nov 1;49(11):e1063-e1143. doi: 10.1097/CCM.0000000000005337.
Abstract/Text
PMID 34605781
Mitchell M Levy, Laura E Evans, Andrew Rhodes
The Surviving Sepsis Campaign Bundle: 2018 update.
Intensive Care Med. 2018 Jun;44(6):925-928. doi: 10.1007/s00134-018-5085-0. Epub 2018 Apr 19.
Abstract/Text
PMID 29675566
J Garnacho-Montero, A Gutiérrez-Pizarraya, A Escoresca-Ortega, Y Corcia-Palomo, Esperanza Fernández-Delgado, I Herrera-Melero, C Ortiz-Leyba, J A Márquez-Vácaro
De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock.
Intensive Care Med. 2014 Jan;40(1):32-40. doi: 10.1007/s00134-013-3077-7. Epub 2013 Sep 12.
Abstract/Text PURPOSES: We set out to assess the safety and the impact on in-hospital and 90-day mortality of antibiotic de-escalation in patients admitted to the ICU with severe sepsis or septic shock.
METHODS: We carried out a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock. De-escalation was defined as discontinuation of an antimicrobial agent or change of antibiotic to one with a narrower spectrum once culture results were available. To control for confounding variables, we performed a conventional regression analysis and a propensity score (PS) adjusted-multivariable analysis.
RESULTS: A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9%). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95% confidence interval (CI) 0.36-0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95% CI 0.33-0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality.
CONCLUSIONS: De-escalation therapy for severe sepsis and septic shock is a safe strategy associated with a lower mortality. Efforts to increase the frequency of this strategy are fully justified.

PMID 24026297
Michael Klompas, Richard Branson, Eric C Eichenwald, Linda R Greene, Michael D Howell, Grace Lee, Shelley S Magill, Lisa L Maragakis, Gregory P Priebe, Kathleen Speck, Deborah S Yokoe, Sean M Berenholtz, Society for Healthcare Epidemiology of America (SHEA)
Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update.
Infect Control Hosp Epidemiol. 2014 Aug;35(8):915-36. doi: 10.1086/677144.
Abstract/Text
PMID 25026607
Zhikang Ye, Annika Reintam Blaser, Lyubov Lytvyn, Ying Wang, Gordon H Guyatt, J Stephen Mikita, Jamie Roberts, Thomas Agoritsas, Sonja Bertschy, Filippo Boroli, Julie Camsooksai, Bin Du, Anja Fog Heen, Jianyou Lu, José M Mella, Per Olav Vandvik, Robert Wise, Yue Zheng, Lihong Liu, Reed A C Siemieniuk
Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline.
BMJ. 2020 Jan 6;368:l6722. doi: 10.1136/bmj.l6722. Epub 2020 Jan 6.
Abstract/Text CLINICAL QUESTION: What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.
CURRENT PRACTICE: Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.
RECOMMENDATIONS: This guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).
HOW THIS GUIDELINE WAS CREATED: A guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable.
THE EVIDENCE: The linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty).
UNDERSTANDING THE RECOMMENDATION: In most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID 31907223

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