Increased sodium intake and decreased sodium excretion in ICU-acquired hypernatremia:A prospective cohort study

PURPOSE: To provide more in-depth insight in the development of early ICU-acquired hypernatremia in critically ill patients based on detailed, longitudinal and quantitative data.MATERIALS AND METHODS: A comparative analysis was performed using prospectively collected data of ICU patients. All patients requiring ICU admission for more than 48 h between April and December 2018 were included. For this study, urine samples were collected daily and analyzed for electrolytes and osmolality. Additionally, plasma osmolality analyses were performed. Further data collection consisted of routine laboratory results, detailed fluid balances and medication use.RESULTS: A total of 183 patient were included for analysis, of whom 38% developed ICU-acquired hypernatremia. Whereas the hypernatremic group was similar to the non-hypernatremic group at baseline and during the first days, hypernatremic patients had a significantly higher sodium intake on day 2 to 5, a lower urine sodium concentration on day 3 and 4 and a worse kidney function (plasma creatinine 251 versus 71.9 μmol/L on day 5). Additionally, hypernatremic patients had higher APACHE IV scores (67 versus 49, p &lt; 0.05) and higher ICU (23 versus 12%, p = 0.07) and 90-day mortality (33 versus 14%, p &lt; 0.01).CONCLUSIONS: Longitudinal analysis shows that the development of early ICU-acquired hypernatremia is preceded by increased sodium intake, decreased renal function and decreased sodium excretion.</p

Comparison of outcome and characteristics between 6343 COVID-19 patients and 2256 other community-acquired viral pneumonia patients admitted to Dutch ICUs

Purpose: Describe the differences in characteristics and outcomes between COVID-19 and other viral pneumonia patients admitted to Dutch ICUs. Materials and methods: Data from the National-Intensive-Care-Evaluation-registry of COVID-19 patients admitted between February 15th and January 1th 2021 and other viral pneumonia patients admitted between January 1st 2017 and January 1st 2020 were used. Patients' characteristics, the unadjusted, and adjusted in-hospital mortality were compared. Results: 6343 COVID-19 and 2256 other viral pneumonia patients from 79 ICUs were included. The COVID-19 patients included more male (71.3 vs 49.8%), had a higher Body-Mass-Index (28.1 vs 25.5), less comorbidities (42.2 vs 72.7%), and a prolonged hospital length of stay (19 vs 9 days). The COVID-19 patients had a significantly higher crude in-hospital mortality rate (Odds ratio (OR) = 1.80), after adjustment for patient characteristics and ICU occupancy rate the OR was respectively 3.62 and 3.58. Conclusion: Higher mortality among COVID-19 patients could not be explained by patient characteristics and higher ICU occupancy rates, indicating that COVID-19 is more severe compared to other viral pneumonia. Our findings confirm earlier warnings of a high need of ICU capacity and high mortality rates among relatively healthy COVID-19 patients as this may lead to a higher mental workload for the staff. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/)

Cholesterol in the ICU: A cheap and reliable marker for illness severity?

Several markers as C-reactive protein and procalcitonin are used in the ICU to monitor the success of the treatment. Recently, studies about the prognostic value of cholesterol have been reported. In this case series we discuss cholesterol as a cheap and reliable marker for daily follow up, to monitor improvement or deterioration of patients in the ICU

Elektronische beslissingsondersteuning in de zorg:Enorme potentie, complexe implementatie

Zorgprofessionals nemen dagelijks veel beslissingen ten aanzien van de zorg voor hun patiënten. Deze dagelijkse medische besluitvorming wordt steeds moeilijker door de intrinsieke complexiteit en interacties van de aandoeningen binnen een ouder wordende bevolking. Daarnaast wordt de besluitvorming beïnvloed door andere factoren op de werkvloer, zoals wisseling in personeel, de variatie aan kennis en ervaring binnen het personeel, de hoge intensiteit van het werk en alle administratieve taken. Als laatste blijven medische data en kennis toenemen waardoor het verkrijgen van een overzicht van het patiëntdossier lastig is. Elektronische klinische beslissingsondersteunende systemen kunnen zorgprofessionals ondersteunen bij het verkrijgen van dit overzicht en de dagelijkse besluitvorming, maar de invoering van deze systemen blijft achter. In dit artikel wordt ingegaan op de uitdagingen en belemmeringen die rondom de ontwikkeling en invoering van klinische beslissingsondersteunende systemen bestaan

Clinical validation of a computerized algorithm to determine mean systemic filling pressure

Mean systemic filling pressure (Pms) is a promising parameter in determining intravascular fluid status. Pms derived from venous return curves during inspiratory holds with incremental airway pressures (Pms-Insp) estimates Pms reliably but is labor-intensive. A computerized algorithm to calculate Pms (Pmsa) at the bedside has been proposed. In previous studies Pmsa and Pms-Insp correlated well but with considerable bias. This observational study was performed to validate Pmsa with Pms-Insp in cardiac surgery patients. Cardiac output, right atrial pressure and mean arterial pressure were prospectively recorded to calculate Pmsa using a bedside monitor. Pms-Insp was calculated offline after performing inspiratory holds. Intraclass-correlation coefficient (ICC) and assessment of agreement were used to compare Pmsa with Pms-Insp. Bias, coefficient of variance (COV), precision and limits of agreement (LOA) were calculated. Proportional bias was assessed with linear regression. A high degree of inter-method reliability was found between Pmsa and Pms-Insp (ICC 0.89; 95%CI 0.72-0.96, p = 0.01) in 18 patients. Pmsa and Pms-Insp differed not significantly (11.9 mmHg, IQR 9.8-13.4 vs. 12.7 mmHg, IQR 10.5-14.4, p = 0.38). Bias was -0.502 +/- 1.90 mmHg (p = 0.277). COV was 4% with LOA -4.22 - 3.22 mmHg without proportional bias. Conversion coefficient Pmsa -> Pms-Insp was 0.94. This assessment of agreement demonstrates that the measures Pms-Insp and the computerized Pmsa-algorithm are interchangeable (bias - 0.502 +/- 1.90 mmHg with conversion coefficient 0.94). The choice of Pmsa is straightforward, it is non-interventional and available continuously at the bedside in contrast to Pms-Insp which is interventional and calculated off-line. Further studies should be performed to determine the place of Pmsa in the circulatory management of critically ill patients

Using a clinical decision support sytem to determine the quality of antimicrobial dosing in intensive care patients with renal insufficiency

Background The benefits on clinical practice of a clinical decision support system (CDSS) are predominantly determined by the quality of the clinical rules used in this system. Therefore, it is essential to investigate the performance and potential benefits on quality of care of these rules. Methods A clinical rule assisting physicians in selecting the appropriate dosage according to renal function of frequently prescribed antimicrobials was developed. In 2004, 1788 patients admitted to the intensive care unit (ICU) for more than 12 h were included in this retrospective study. The actual number of dosage adjustments without the support of the CDSS was compared with the theoretical number of dosage adjustments determined by the clinical rule in patients with moderate (creatinine clearance (Clcreat) 10–50 ml/min) and severe (Clcrea

Intelligent dynamic clinical checklists improved checklist compliance in the intensive care unit

Background: Checklists can reduce medical errors. However, the use of checklists is hampered by lack of acceptance and compliance. Recently, a new kind of checklist with dynamic properties has been created to provide more specific checklist items of a patient to the specific caregiver. Our purpose of this simulation based study was to investigate the first developed intelligent dynamic clinical checklist (DCC) for the Intensive Care Unit (ICU) ward round. METHODS: Eligible clinicians were invited to participate as volunteers. Highest achievable scores were established for six typical ICU scenarios to determine which items must be checked. The participants compared the DCC with the local standard of care. The primary outcomes were the caregiver satisfaction score and, the percentages of checked items overall and of critical items requiring a direct intervention. RESULTS: In total twenty participants were included, who performed 116 scenarios. The median percentage of checked items was 100.0% with the DCC, compared to 73.6% for the scenarios completed with local standard of care (p<0.001). In the scenarios performed with local standard of care remained 23.1% of the critical items unchecked, in contrast to 0.0% if the DCC was available (p<0.001). The mean satisfaction score of the DCC was 4.13 out of 5. CONCLUSION: This simulation study indicates that an intelligent DCC significantly increases compliance to best practice by reducing the percentage of unchecked items during ICU ward rounds, while the user satisfaction rate remains high. More, real life, clinical research is required to further evaluate this new kind of checklist

Differences in identification of patients' deterioration may hamper the success of clinical escalation protocols

BACKGROUND: Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards. AIM: To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it. DESIGN: An international survey. METHODS: Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis. RESULTS: A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to. CONCLUSION: This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required

Effects of fish oil on oxidation resistance of VLDL in hypertriglyceridemic patients

In hypertriglyceridemic (HTG) patients the addition of fish oil to the diet causes a marked reduction in the concentration of triglyceride-rich lipoproteins in the serum. To investigate the effects of fish oil on the oxidation resistance of VLDL and LDL in HTG patients, nine male patients received 1 g/d fish oil (containing 55.7% n-3 polyunsaturated fatty acids [PUFAs] and 1 U α-tocopherol/g fish oil) for 6 weeks followed by 5 g/d fish oil for an additional 6 weeks. Cu2+ -induced oxidation of VLDL and LDL was measured by continuous monitoring of conjugated dienes. Supplementation with 1 g/d fish oil caused hardly any changes in the n-3 PUFA content of lipoproteins or lipoprotein concentrations in serum. However, supplementation with 5 g/d fish oil resulted in a significant increase of n-3 PUFA content in VLDL (from 2.5% to 6.4% of total fatty acids) and LDL (from 3.2% to 6.4% of total fatty acids), decreases in serum triglyceride, VLDL triglyceride, and VLDL cholesterol concentrations of 54%, 56%, and 40%, respectively, and an increase in LDL Cholesterol of 23%. The lag times of VLDL and LDL oxidation decreased from 197 to 140 minutes (-29%)and 101 to 86 minutes (-15%), respectively. At the end of the 5 g/d fish oil supplementation the lag times of VLDL and LDL oxidation were correlated with their respective n-3 PUFA content (r= -.67; P<.05 and r = -.79; P<.02, respectively). Before and at the end of supplementation with 5 g/d fish oil the lag times and propagation tales of VLDL oxidation also correlated with the total number of double bonds in all PUFAs of VLDL. We conclude that fish oil supplementation strongly reduces serum concentrations of total triglycerides, VLDL triglycerides, and VLDL cholesterol. However, in HTG patients fish oil supplementation increased the serum LDL cholesterol concentration and the susceptibility of VLDL and LDL to oxidation