Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations.

OBJECTIVE: To report the ESICM consensus and clinical practice recommendations on fluid therapy in neurointensive care patients. DESIGN: A consensus committee comprising 22 international experts met in October 2016 during ESICM LIVES2016. Teleconferences and electronic-based discussions between the members of the committee subsequently served to discuss and develop the consensus process. METHODS: Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles generated. The consensus focused on three main topics: (1) general fluid resuscitation and maintenance in neurointensive care patients, (2) hyperosmolar fluids for intracranial pressure control, (3) fluid management in delayed cerebral ischemia after subarachnoid haemorrhage. After an extensive literature search, the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were applied to assess the quality of evidence (from high to very low), to formulate treatment recommendations as strong or weak, and to issue best practice statements when applicable. A modified Delphi process based on the integration of evidence provided by the literature and expert opinions-using a sequential approach to avoid biases and misinterpretations-was used to generate the final consensus statement. RESULTS: The final consensus comprises a total of 32 statements, including 13 strong recommendations and 17 weak recommendations. No recommendations were provided for two statements. CONCLUSIONS: We present a consensus statement and clinical practice recommendations on fluid therapy for neurointensive care patients

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. 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. 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. 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

Adenosine triphosphate-magnesium chloride: relevance for intensive care.

International audienceBACKGROUND: Despite aggressive resuscitation shock often results in multiple-organ failure characterized by increased energy demands of organs and decreased ability of effective energy production. The administration of ATP-MgCl(2) as a supportive measure has been investigated in various animal models of ischemia/reperfusion injury and hemorrhagic, endotoxic, and septic shock. INVESTIGATIONS: These studies showed improvement in organ blood flow, microcirculation, energy balance, cellular and mitochondrial, functions and restoration of immune competence, ultimately leading to increased survival. Originally these effects were attributed to direct energy provision by the ATP-Mg complex, but the minute amount of ATP infused compared to the body's ATP formation rate suggests that other mechanisms must be responsible for its beneficial properties such as stabilization of the cell membrane, phosphorylation of membrane proteins, decreased cell swelling, and improved microcirculatory perfusion. CONCLUSIONS: The experimental evidence currently available suggests the use of ATP-MgCl(2) as a therapeutic adjunct in patients with multiple-organ dysfunction. In addition, given the extremely short half-life which allows both rapid titration and control of the systemic hemodynamic response, for example, reduction in mean arterial pressure, ATP-MgCl(2) may be suitable as an alternative to other fast-acting vasodilators used for the management of acute pulmonary hypertensive crises and/or for the maintenance blood pressure during aortic cross-clamping

Acute respiratory failure after drowning: a retrospective multicenter survey

International audienceOBJECTIVES:Despite the extensive literature on drowning, clinical data are still lacking on the best medical strategy to use. Acute respiratory failure (ARF) is the main component of drowning pathophysiology. The objectives of this multicenter study were to analyze the clinical course of drowning-related ARF patients and to describe the efficacy of the ventilatory strategies used.METHODS:Medical records of drowned adult patients admitted in seven ICUs after prehospital emergency medical care during three consecutive summer periods were retrospectively analyzed.RESULTS:Among the 126 patients (58±21 years) admitted, 38 patients with cardiac arrest at the scene were not analyzed, 26 received mechanical ventilation (MV), and 48 patients received noninvasive ventilation (NIV). Compared with patients placed under MV, the NIV patients presented a better initial neurological (Glasgow Coma Scale of 7±4 vs. 12±3, P<0.05) and hemodynamic status from the prehospital stage (mean arterial pressure of 77±18 vs. 96±18, P<0.001). With comparable ARF-related hypoxemia to MV, the NIV was maintained with success in 92% (44/48). Both MV and NIV were associated with rapid improvement of oxygenation and short ICU length of stay [3 (1-14) and 2 (1-7), respectively].CONCLUSION:Despite the absence of recommendation for NIV use in case of drowning-related ARF, this technique was often used with safety and efficacy. The decision for NIV use was mainly based on the preserved or improved neurological status

Facteurs pronostiques issus du contrôle glycémique en réanimation : de nouveaux objectifs grâce à l’étude CGAO-REA ?

International audienceIntroductionLes objectifs du contrôle glycémique en réanimation se sont complexifiés depuis la première étude de Louvain [1] mettant en évidence une réduction de mortalité associée au seul respect d’une cible glycémique stricte (4,4–6,1 mmol/L). Au-delà de la controverse concernant la cible glycémique qui s’en est suivie, hypoglycémie et variabilité glycémique élevée seraient associées à un pronostic défavorable [2]. Le but de l’étude est de vérifier si ces associations existent dans le collectif de patients inclus dans l’étude multicentrique CGAO-REA visant à comparer l’impact sur la mortalité à J90 d’un contrôle glycémique informatisé strict (4,4–6,1 mmol/L) à un contrôle glycémique conventionnel (< 10 mmol/L) [3].Matériel et méthodesPour chacun des 2556 patients (parmi les 2648 randomisés analysables de l’étude CGAO-REA) pour lesquels les données de monitorage glycémique étaient disponibles, nous avons déterminé, pour l’ensemble du séjour en réanimation, la glycémie minimale Gmin, la glycémie maximale Gmax, la différence Gmax–Gmin, et la glycémie moyenne. La division en quintiles de la distribution de ces paramètres descriptifs du contrôle glycémique a permis de construire 5 groupes de patients pour chaque paramètre. La mortalité à J90 a été déterminée dans chacun des groupes et comparée à l’aide d’un test Chi2 à la mortalité attendue.RésultatsParmi les 2556 patients, 835 sont décédés à J90 (mortalité attendue 32,7 %). Les 4 graphiques suivants indiquent la mortalité dans chacun des quintiles pour chaque paramètre (Fig. 1)DiscussionL’analyse des patients inclus dans l’étude CGAO-REA semble confirmer l’association entre hypoglycémie et variabilité glycémique et pronostic défavorable

Contrôle glycémique strict informatisé en réanimation : étude multicentrique prospective contrôlée randomisée (étude CGAO-REA)

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Effects of tight computerized glucose control on neurological outcome in severely brain injured patients: A multicenter sub-group analysis of the randomized-controlled open-label CGAO-REA study.

International audienceIntroduction: Hyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little dataregarding the effects of intensive insulin therapy (IIT) on neurological recovery.Methods: A sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensivecare units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length ofstay ≥48 hours were included. Patients were randomized between a conventional glucose management group(blood glucose target between 5.5 and 9 mmol.L−1) and an IIT group (blood glucose target between 4.4 and6 mmol.L−1). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale.Results: A total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the controlgroup and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (±4). Patients in the IIT groupreceived more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantlylower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L−1 versus 6.5 (5.6 to 7.2) mmol.L−1, P <0.001) in the first5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P <0.0001). In the IIT group24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31(31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemiadid not influence the outcome.Conclusions: In this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidit

Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients

International audienceIntroduction Using a randomized controlled trial comparing tight glucose control with a computerized decision-support systems and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. Methods We looked for moderate (2.2-3.3mmol/l) and severe (&lt;2.2mmol/l) hypoglycemia, multiple hypoglycemic events (n[greater than or equal to]3), and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary end-point was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm, caliper width of 105 digit with no replacement). Results A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n=1,474), moderate hypoglycemia (n=874, 34%), and severe hypoglycemia (n=253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis as shown by a higher mortality rate (36% and 54% respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (OR 1.50, 95% CI 1.36-1.56, P=0.043) and multiple hypoglycemic events (OR 1.76, 95% CI 1.31-3.37, P&lt;0.001) were significantly associated with mortality whereas blood glucose CV was not. Using multivariable matching, patients with severe (53 vs. 35%, P&lt;0.001), moderate (33 vs. 27%, P=0.029), and multiple hypoglycemic events (46 vs. 32%, P&lt;0.001), had a higher 90-day mortality. Conclusion In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality. Trial registration Clinicaltrials.gov Identifier NCT01002482 Registered 26 Octobrer 2009