Should we measure intra-abdominal pressures in every intensive care patient?

Intra-abdominal pressure (IAP) is seldom measured by default in intensive care patients. This review summarises the current evidence on the prevalence and risk factors of intra-abdominal hypertension (IAH) to assist the decision-making for IAP monitoring

Tsentraalvenoosse rõhu interpretatsioon sepsisega intensiivravihaigetel

Südame eelkoormuse ja seeläbi kaudselt ka ringleva vere mahu hindamisel on aastakümneid lähtutud südame täitumisrõhkudest ehk tsentraalvenoossest rõhust (CVP) ning kopsuarteri kinnikiilumisrõhust. Viimasel aastakümnel tehtud uuringute käigus on selgunud, et südame täitumisrõhud ei anna küllaldast ülevaadet südame eelkoormusest ega ole heaks parameetriks infusioonravi juhtimisel. Eesmärgiga hinnata CVP kui eelkoormuse näitaja interpretatsioonivõimalusi uuriti arteriaalse vere hapnikusisalduse ja sissehingatava õhu hapnikukontsentratsiooni suhte sõltuvust CVPst ning väljahingamise lõpp-positiivse rõhu mõju CVP-le sepsisega intensiivravihaigetel. Leiti, et kõrgenenud CVP ei viita alati hüpervoleemiale ning sellest tingitud kopsufunktsiooni halvenemisele. Seetõttu tuleks CVP absoluutväärtuste kasutamisse infusioonravi juhtimise kriteeriumina suhtuda ettevaatusega

Intra-Abdominal Hypertension and Gastrointestinal Symptoms in Mechanically Ventilated Patients

Background. We aimed to describe the incidence of intra-abdominal hypertension (IAH) and gastrointestinal (GI) symptoms and related outcome in mechanically ventilated (MV) patients. Methods. Intra-abdominal pressure (IAP) and gastric residual volumes were measured at least twice daily. IAH was defined as a mean daily value of IAP ≥ 12 mmHg. Results. 398 patients were monitored for all together 2987 days. GI symptom(s) occurred in 80.2% patients. 152 (38.2%) patients developed IAH. Majority (93.4%) of patients with IAH had GI symptoms. The more severe IAH was associated with the higher number of concomitant GI symptoms (P < .001). 142 (35.7%) patients developed both IAH and at least one GI symptom at any time in ICU, and in 77 patients they occurred simultaneously on the same day. This subgroup had the highest ICU mortality (21.8%). In contrast, the small group of patients presenting only IAH, but not GI symptoms (10 patients), had no lethal outcome. Three patients (4.4%) died without showing either IAH or GI symptoms. Conclusions. GI symptoms and IAH often, but not always, occur together. The patients having IAH solely without developing GI symptoms have rather good outcome

Seedetraktipuudulikkuse levimus aparaadihingamisel intensiivravihaigetel

Uuringu eesmärk. Kirjeldada 2008. a Eestis välja töötatud seedetraktipuudulikkuse skoori (Gastrointestinal Failure (GIF) score, GIF-skoor) abil seedetraktipuudulikkuse esinemist ja mõju ravi lõpptulemusele aparaadihingamist vajavatel intensi ivravipatsientidel. GIFskoor väljendab seedetraktipuudulikkust intraabdominaalne hüpertensiooni (IAH) ja enteraalse toitmise ebaõnnestumise kombinatsioonina. Metoodika. Prospektiivne levimusuuring. Uuritavateks olid kõik järjestikused intensiivraviosakonnas vähemalt 24 tundi aparaadihingamisel olnud täiskasvanud patsiendid (n = 389). Tulemused. IAH arenes 115 (29,6%) patsiendil ja enteraalne toitmine ebaõnnestus 210 patsiendil (54,5%). Seedetraktipuudulikkus (GIF-skoor vähemalt ühel päeval vähemalt 3 punkti) esines 67 haigel (17,2%). Haigete suremus erinevate GIF-skoori gruppides oli korrelatsioonis sündroomi raskusega. GIF-skoori kombineerimine SOFA hulgielundipuudulikkuse skooriga ei suurenda viimase ennustusjõudu suremuse prognoosimisel. Järeldused. Enteraalse toitmise ebaõnnestumine ja IAH esinevad aparaadihingamisel intensiivravihaigetel sageli. GIF-skoor korreleerub suremusega. Edasised uuringud on vajalikud, et selgitada, kas GIF-skoor on kasutatav SOFAskoori täiendina. Eesti Arst 2010; 89(11):708−71

Abdominaalse kompartmentsündroomi levimus ning ravitulemused TÜ Kliinikumi üldintensiivravi osakonnas aastatel 2004–2006

Uuringu eesmärk oli analüüsida abdominaalse kompartmentsündroomi (AKS) levimust, rutiinseid ravimeetodeid ning elulemust TÜ Kliinikumi üldintensiivravi osakonna andmetel aastatel 2004–2006. Andmed koguti prospektiivselt, analüüs tehti retrospektiivselt. Sel perioodil viibis üldintensiivravi osakonnas ravil kokku 1077 patsienti, intraabdominaalset rõhku (IAP) mõõdeti neist 370-l. Kokku 15 patsiendil kujunes välja AKS. AKSiga patsientide suremus oli 66,7%. AKS-diagnoos ei kajastunud üheski haigusloos, neljal juhul mainiti seda decursus’es. Konservatiivsetest ravimeetoditest kasutati kõigil patsientidel passiivset nasogastraalaspiratsiooni, seitsmel patsiendil narkoosi süvendamist ja kuuel lahtisteid. Dekompressiivne laparotoomia tehti kahele patsiendile. Eesti Arst 2009; 88(4):234−24

Intraabdominaalse hüpertensiooni esinemissagedus intensiivravihaigetel ja mõju ravitulemustele

Tartu Ülikooli Kliinikumi üldintensiivraviosakonnas on intraabdominaalset rõhku (IAP) mõõdetud alates 2004. aastast. Käesolev töö keskendub intraabdominaalse hüpertensiooni (IAH) esinemissageduse ja mõju uurimisele kahe perioodi võrdluses: esimesel perioodil (2004–2006) mõõdeti IAP ainult eeldatava riskirühma patsientidel, teisel perioodil (2006–2007) aga kõikidel aparaadihingamisel olevatel haigetel. Uurimuse tulemustest selgus, et IAH riskirühm on raskesti kindlaks tehtav. Jälgides IAPd ainult valitud patsientidel, jääb osa IAH-patsientidest identifi tseerimata. IAH esineb intensiivravipatsientidel sageli ning on seotud nende suurema suremusega. Eesti Arst 2008; 87(3):191−19

Implementation of enteral feeding protocol in an intensive care unit:Before-and-after study

AIM: To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients. METHODS: An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital’s Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed. RESULTS: In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower cumulative amount of parenterally (P < 0.001) provided calories by day 7, with an overall reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition. CONCLUSION: The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension

Gastrointestinal Failure score in critically ill patients: a prospective observational study

© 2008 Reintam et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution Licens

Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems

Purpose: Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options. Methods: The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology. Results: Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I=increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II=GI dysfunction (a condition that requires interventions); AGI grade III=GI failure (GI function cannot be restored with interventions); AGI grade IV=dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided. Conclusions: State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purpose

Gastrointestinal symptoms during the first week of intensive care are associated with poor outcome : a prospective multicentre study

The study aimed to develop a gastrointestinal (GI) dysfunction score predicting 28-day mortality for adult patients needing mechanical ventilation (MV). 377 adult patients from 40 ICUs with expected duration of MV for at least 6 h were prospectively studied. Predefined GI symptoms, intra-abdominal pressures (IAP), feeding details, organ dysfunction and treatment were documented on days 1, 2, 4 and 7. The number of simultaneous GI symptoms was higher in nonsurvivors on each day. Absent bowel sounds and GI bleeding were the symptoms most significantly associated with mortality. None of the GI symptoms alone was an independent predictor of mortality, but gastrointestinal failure (GIF)-defined as three or more GI symptoms-on day 1 in ICU was independently associated with a threefold increased risk of mortality. During the first week in ICU, GIF occurred in 24 patients (6.4 %) and was associated with higher 28-day mortality (62.5 vs. 28.9 %, P = 0.001). Adding the created subscore for GI dysfunction (based on the number of GI symptoms) to SOFA score did not improve mortality prediction (day 1 AUROC 0.706 [95 % CI 0.647-0.766] versus 0.703 [95 % CI 0.643-0.762] in SOFA score alone). An increasing number of GI symptoms independently predicts 28 day mortality with moderate accuracy. However, it was not possible to develop a GI dysfunction score, improving the performance of the SOFA score either due to data set limitations, definition problems, or possibly indicating that GI dysfunction is often secondary and not the primary cause of other organ failure