Peri-operative blood pressure changes in normotensive and hypertensive patients

Controversy surrounds the acceptance of hypertension as an independent risk factor for anaesthesia. In an attempt to identify variables that are associated with increased haemodynamic instability during surgery, the blood pressure profiles of 128 patients were analysed. The two variables that contributed most to the instability were pre-operative control of blood pressure and anaesthetic technique. To reduce the fluctuation in blood pressure, it is advisable for patients to be given a regional anaesthetic. Current therapy for hypertension appears to exaggerate the depressant effects of anaesthetic drugs. Care must be taken not only to prevent hypertensive episodes during surgery, but also hypotensio

Nutritional management of the critically ill obese patient

Purpose of review: The prevalence of obesity in Malaysia has increased four folds over the past two decades. Epidemiologic studies suggest that there are increased numbers of overweight and obese patients admitted to the intensive care unit (ICU). Increased morbidity and mortality along with longer duration of ICU stay and time on mechanical ventilator have been shown to be associated with this particular body habitus. This review will discuss the recent findings and evidence-based approaches to provide nutrition therapy for this ICU population. Recent findings: Nutrition therapy plays a vital role in improving their outcome; however, clinicians need knowledge of certain obstacles that are unique to obese patients. Nutrition assessment should be comprehensive, because the presence of malnutrition is always underestimated. The increased basal insulin level suppresses lipid mobilisation but increases protein breakdown in obesity, thus leading to protein malnutrition. Large variations in body composition among the obese make estimation of caloric requirements very difficult. There is no consensus as to which predictive equation is most suitable, leading to the recommendation to perform indirect calorimetry when available. A more balanced nitrogen profile has been shown following a high-protein, hypocaloric feeding regimen as compared to a eucaloric one while also demonstrating better outcomes. Summary: Future studies should focus on finding a method to determine appropriate energy requirements and validate the benefits of a high-protein, hypocaloric feeding regimen in critically ill obese patients

Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: a prospective observational study

Background & aims: The effect of provision of full feeding or permissive underfeeding on mortality in mechanically ventilated critically ill patients in the intensive care unit (ICU) is still controversial. This study investigated the relationship of energy and protein intakes with 60-day mortality, and the extent to which ICU length of stay and nutritional risk status influenced this relationship. Methods: This is a prospective observational study conducted among critically ill patients aged ≥18 years, intubated and mechanically ventilated within 48 h of ICU admission and stayed in the ICU for at least 72 h. Information on baseline characteristics and nutritional risk status (the modified Nutrition Risk in Critically ill [NUTRIC] score) was collected on day 1. Nutritional intake was recorded daily until death, discharge, or until the twelfth evaluable days. Mortality status was assessed on day 60 based on the patient's hospital record. Patients were divided into 3 groups a) received <2/3 of prescribed energy and protein (both <2/3), b) received ≥2/3 of prescribed energy and protein (both ≥2/3) and c) either energy or protein received were ≥2/3 of prescribed (either ≥2/3). The relationship between the three groups with 60-day mortality was examined by using logistic regression with adjustment for potential confounders. Sensitivity analysis was performed to examine the influence of ICU length of stay (≥7 days) and nutritional risk status. Results: Data were collected from 154 mechanically ventilated patients (age, 51.3 ± 15.7 years; body mass index, 26.5 ± 6.7 kg/m2; 54% male). The mean modified NUTRIC score was 5.7 ± 1.9, with 56% of the patients at high nutritional risk. The patients received 64.5 ± 21.6% of the amount of energy and 56.4 ± 20.6% of the amount of protein prescribed. Provision of energy and protein at ≥2/3 compared with <2/3 of the prescribed amounts was associated with a trend towards increased 60-day mortality (Adjusted odds ratio [Adj OR] 2.23; 95% confidence interval [CI], 0.92-5.38; p = 0.074). No difference in mortality status was found between energy and protein provision at either ≥2/3 compared with <2/3 of the prescribed amounts (Adj OR 1.61, 95% CI, 0.58-4.45; p = 0.357). Nutritional risk status, not ICU length of stay, influenced the relationship between nutritional adequacy and 60-day mortality. Conclusions: Energy and protein adequacy of ≥2/3 of the prescribed amounts were associated with a trend towards increased 60-day mortality among mechanically ventilated critically ill patients. However, neither energy nor protein adequacy alone at ≥ or <2/3 adequacy affect 60-day mortality. Increased mortality was associated with provision of energy and protein at ≥2/3 of the prescribed amounts, which only affected patients with low nutritional risk

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit

Objectives: Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. Methods: Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. Results: A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. Conclusions: EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team

Comparison between the effects of high sevoflurane concentration during induction of anasesthesia using vital capacity breath and tidal breathing techniques in adults

Introduction: The aims of this randomised study were to compare the induction characteristics of sevoflurane using vital capacity breath technique to that of tidal breathing technique in adults undergoing day-care surgery, and to compare patients’ acceptance of these two techniques. Methods: Sixty ASA I and II adult patient undergoing day-care surgery were randomly allocated to receive either the vital capacity breath or tidal breathing technique for induction of anaesthesia with 7.5% sevoflurane in nitrous oxide and oxygen. Haemodynamic changes, induction characteristics and patients acceptance were compared. Results: The mean time for induction was significantly faster with the vital capacity breath technique. There were no significant differences in haemodynamic changes and oxygenation during induction between these two groups. There was significant increase in incidence of excitatory movement in patient receiving the tidal breathing technique. Either technique was found to be acceptable by most of the patients studied. Conclusion: The vital capacity breath technique appears to be better tolerated with shorter onset time and less movement during induction of anaesthesia. As it is well accepted by the patients and has a stable haemodynamic profile, its use should be encouraged

Enhanced protein-energy provision via the enteral route in critically ill patients (PEP uP protocol): a review of evidence

Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol

Feeding adequacy among critically ill patients in the Intensive Care Unit and its association with clinical outcomes: a narrative review

The Intensive Care Unit (ICU) is one of the disciplines in the hospital that provides close monitoring to the seriously ill or injured patients, also known as the critically ill patients. Critically ill patients in the ICU are usually unable to maintain volitional oral nutrition intake and therefore require nutritional therapy. Nutritional therapy can be delivered via the enteral or parenteral route. Optimal nutrition adequacy (i.e. neither underfeeding nor overfeeding) is very important for better clinical outcome. However, the problem of suboptimal feeding adequacy continues to be reported over the years. This article attempts to give an overview of the literature on feeding adequacy and the relationship of feeding adequacy with clinical outcomes among the critically ill patients in the ICU

Guide to antimicrobial therapy in the adult ICU 2012

Sepsis still remains one of the commonest cause of ntensive care admission here in Malaysia. In the last six years following the first edition, there has been burgeoning increase in knowledge and usage of antimicrobials. However the pressing issues of growing antimicrobial resistance, inappropriate therapy and escalating cost compel for a more responsible prescriber. In order to keep pace with important advances, most chapters have been revised and others eliminated. The objective of this book has not strayed from its original purpose that is to provide a quick and comprehensive guide for the Malaysian doctors caring for the critically ill. The structure has been kept to facilitate easy bedside referencing. The notations have expanded to explain the rationale behind antibiotic choices. Hence we hope this handbook will add to the armamentarium of those who work in intensive care units. The first revision of the ‘The MSA Guide to Antimicrobial Therapy in the Adult ICU’ has been assumed by the Malaysian Society of Intensive Care. This guide has been a culmination of many hours of evidence review and exchange of opinions. Putting it together to cater to our local needs have been a challenge for us. We would like to thank our external reviewers for their invaluable input and also acknowledge the contribution of the working committee of the first edition: it is on the foundation of their work that the present,Second edition has been developed

Guide to antimicrobial therapy 2017

Sepsis still remains the leading cause of admissions and deaths in the ICU. The administration of antibiotics is imperative in its treatment. Like many areas of medicine the knowledge of sepsis and antibiotic use has markedly increased especially the later in areas of pharmacokinetics and pharmacodynamics. It becomes urgent to continually evaluate and apply this knowledge, hence the need to revise this antimicrobial guide after 5 years. The threat that one day antibiotics may be obsolete is not a fallacy. Often we are oblivious to the fact that we, the prescribers play a significant role in the propagation of resistant organisms through poor prescribing habits. Antibiotic stewardship calls for a multidisciplinary approach to the handling of antibiotics. A chapter has been dedicated to this. The book remains true to its aims as a convenient up-to-date pocket guide for local doctors caring for the critically ill septic patient. However it must be emphasised that the recommendations do not over ride sound clinical judgement and local antibiotic-susceptibility data. We would like to thank our reviewers for their expertise and invaluable recommendations. This book has been a culmination of many hours of evidence review and exchange of opinions. We hope it will be a useful compendium for daily practice

Physiological and psychological effects of listening to Holy Quran Recitation in the Intensive Care Unit patients: a systematic review

Stress and anxiety are common among intensive care unit (ICU) patients especially those who are on mechanical ventilation. Non-pharmacological interventions such as music and prayer are recommended because they are opioid sparing, easy to provide, cheap and safe. There is a growing body of evidence on the effects of Holy Quran Recitation (HQR) in reducing stress and anxiety in critically ill Muslim patients. The aim of this review is to evaluate the physiological and psychological effects of HQR specifically in ICU setting. This review was performed on articles published between 2007 and 2018. Extensive search was done using PubMed, ISI Web of Knowledge, Scopus and Google Scholar. Systematic review articles are also assessed and relevant literatures are hand searched based on reference lists and citations made in key publications. Studies related to HQR which were done outside adult ICU setting were excluded. A total of nine articles are included in the final list for detail analysis. Findings of this review revealed six studies with significant results in improving stress responses, hemodynamic stability and conscious levels. HQR is a potential non-pharmacological tool to reduce stress and can also be used as auditory stimulus to improve conscious level in comatose patients. More studies in this area are recommended aiming for low risk of bias, appropriate calculation of sample size and adequately powered to detect significant outcomes