A single-center prospective observational study comparing resting energy expenditure in different phases of critical illness: indirect calorimetry versus predictive equations

Objectives: Several predictive equations have been developed for estimation of resting energy expenditure, but no study has been done to compare predictive equations against indirect calorimetry among critically ill patients at different phases of critical illness. This study aimed to determine the degree of agreement and accuracy of predictive equations among ICU patients during acute phase (≤ 5 d), late phase (6–10 d), and chronic phase (≥ 11 d). Design: This was a single-center prospective observational study that compared resting energy expenditure estimated by 15 commonly used predictive equations against resting energy expenditure measured by indirect calorimetry at different phases. Degree of agreement between resting energy expenditure calculated by predictive equations and resting energy expenditure measured by indirect calorimetry was analyzed using intraclass correlation coefficient and Bland-Altman analyses. Resting energy expenditure values calculated from predictive equations differing by ± 10% from resting energy expenditure measured by indirect calorimetry was used to assess accuracy. A score ranking method was developed to determine the best predictive equations. Setting: General Intensive Care Unit, University of Malaya Medical Centre. Patients: Mechanically ventilated critically ill patients. Interventions: None. Measurements and Main Results: Indirect calorimetry was measured thrice during acute, late, and chronic phases among 305, 180, and 91 ICU patients, respectively. There were significant differences (F = 3.447; p = 0.034) in mean resting energy expenditure measured by indirect calorimetry among the three phases. Pairwise comparison showed mean resting energy expenditure measured by indirect calorimetry in late phase (1,878 ± 517 kcal) was significantly higher than during acute phase (1,765 ± 456 kcal) (p = 0.037). The predictive equations with the best agreement and accuracy for acute phase was Swinamer (1990), for late phase was Brandi (1999) and Swinamer (1990), and for chronic phase was Swinamer (1990). None of the resting energy expenditure calculated from predictive equations showed very good agreement or accuracy. Conclusions: Predictive equations tend to either over- or underestimate resting energy expenditure at different phases. Predictive equations with “dynamic” variables and respiratory data had better agreement with resting energy expenditure measured by indirect calorimetry compared with predictive equations developed for healthy adults or predictive equations based on “static” variables. Although none of the resting energy expenditure calculated from predictive equations had very good agreement, Swinamer (1990) appears to provide relatively good agreement across three phases and could be used to predict resting energy expenditure when indirect calorimetry is not available

Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis

This study aims to determine if continuous infusion (CI) is associated with better clinical and pharmacokinetic/pharmacodynamic (PK/PD) outcomes compared to intermittent bolus (IB) dosing in critically ill patients with severe sepsis. This was a two-centre randomised controlled trial of CI versus IB dosing of beta-lactam antibiotics, which enrolled critically ill participants with severe sepsis who were not on renal replacement therapy (RRT). The primary outcome was clinical cure at 14 days after antibiotic cessation. Secondary outcomes were PK/PD target attainment, ICU-free days and ventilator-free days at day 28 post-randomisation, 14- and 30-day survival, and time to white cell count normalisation. A total of 140 participants were enrolled with 70 participants each allocated to CI and IB dosing. CI participants had higher clinical cure rates (56 versus 34 %, p = 0.011) and higher median ventilator-free days (22 versus 14 days, p MIC than the IB arm on day 1 (97 versus 70 %, p < 0.001) and day 3 (97 versus 68 %, p < 0.001) post-randomisation. There was no difference in 14-day or 30-day survival between the treatment arms. In critically ill patients with severe sepsis not receiving RRT, CI demonstrated higher clinical cure rates and had better PK/PD target attainment compared to IB dosing of beta-lactam antibiotics. Continuous beta-lactam infusion may be mostly advantageous for critically ill patients with high levels of illness severity and not receiving RRT

Fiber and prebiotic supplementation in enteral nutrition: A systematic review and meta-analysis

Aim: To investigate fiber and prebiotic supplementation of enteral nutrition (EN) for diarrhea, fecal microbiota and short-chain fatty acids (SCFAs). Methods: MEDLINE, EMBASE, Cochrane Library, CINAHL, Academic Search Premier, and Web of Science databases were searched for human experimental and observational cohort studies conducted between January 1990 and June 2014. The keywords used for the literature search were fiber, prebiotics and enteral nutrition. English language studies with adult patient populations on exclusive EN were selected. Abstracts and/or full texts of selected studies were reviewed and agreed upon by two independent researchers for inclusion in the meta-analysis. Tools used for the quality assessment were Jadad Scale and the Scottish Intercollegiate Guidelines Network Critical Appraisal of the Medical Literature. Results: A total of 456 possible articles were retrieved, and 430 were excluded due to lack of appropriate data. Of the 26 remaining studies, only eight investigated the effects of prebiotics. Results of the meta-analysis indicated that overall, fiber reduces diarrhea in patients receiving EN (OR = 0.47; 95%CI: 0.29-0.77; P = 0.02). Subgroup analysis revealed a positive effect of fiber supplementation in EN towards diarrhea in stable patients (OR = 0.31; 95%CI: 0.19-0.51; P < 0.01), but not in critically ill patients (OR = 0.89; 95%CI: 0.41-1.92; P = 0.77). Prebiotic supplementation in EN does not improve the incidence of diarrhea despite its manipulative effect on bifidobacteria concentrations and SCFA in healthy humans. In addition, the effect of fiber and/or prebiotic supplementation towards fecal microbiota and SCFA remain disputable. Conclusion: Fiber helps minimize diarrhea in patients receiving EN, particularly in non-critically ill patients. However, the effect of prebiotics in moderating diarrhea is inconclusive

Association between energy and protein adequacy with quality of life in mechanically ventilated critically ill patients: a preliminary result

Rationale: There is limited clinical research investigating nutritional adequacy on quality of life (QoL) among survivors in critical care. Methods: This is a prospective observational cohort study conducted among mechanically ventilated critically ill patients. Energy requirements were estimated by Indirect Calorimetry and protein requirements were estimated by 24-h urinary urea. Nutritional intake was recorded daily until death, discharge, or until 14th evaluable day. Eight domains of QoL were assessed by validated SF-36(v2) at six months post-ICU admission. Association between two groups (<70% and ≥70% of energy and protein requirement) with QoL was examined using logistic regression with adjustment for potential confounders. Results: This study aims to determine the association between energy and protein adequacy with QoL among critically ill patients. Of 154 patients, 71 patients (46.1%) were alive, 69 patients (44.8%) died and 14 patients (9.1%) gave no response at 6 months followup. Patient characteristics at follow-up: age 50.6±19.6 years; 62.0% male; body mass index 24.9 (22.3–28.7) kg/m2; APACHE II score 21.2±5.2. Mean QoL score was 58.6±15.9, with scores ≥53 indicating better QoL. Results showed patients with protein, but not energy, adequacy of ≥70% had potential trend towards better QoL though not statistically significant (adjusted OR 2.62; 95%CI 0.80- 8.53; p=0.11). Protein adequacy ≥70% significantly improved bodily pain status (p<0.05), but no significant difference was found in seven other domains of QoL. Conclusion: This preliminary result suggest higher protein adequacy improve Bodily Pain status and may potentially lead towards better overall QoL. We opine that earlier nutrition intervention may assist in improving QoL but needs further investigation

The BLISS study: Beta-Lactam infusion in severe sepsis-randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis in a Malaysian ICU setting

Background: This study aims to determine if continuous infusion (CI) of beta-lactam antibiotics achieves the pharmacokinetic/pharmacodynamic (PK/PD) targets for time-dependent bacterial killing and/or are associated with improved clinical outcomes compared to intermittent bolus (IB) dosing in critically ill patients with severe sepsis. Methods: This is a report from the BLISS Study which was a prospective, multicentre, open-labelled, randomised, controlled trial of CI vs IB dosing of beta-lactam antibiotics, recruiting critically ill patients with severe sepsis from two Malaysian ICUs. The primary end-point, PK/PD target attainment, was evaluated at the halfway point and end of the dosing interval on days 1 and 3 of treatment, by comparing beta-lactam concentrations against causative pathogens based on EUCAST MIC. Secondary end-points were number of days before patient’s white blood cell (WBC) count normalised and that patient’s required infection-related mechanical ventilation (MV), as well as 14-day mortality. Results: 140 critically ill patients with severe sepsis were enrolled with 70 patients each randomly allocated to the CI and IB treatment arms. APACHE II (CI 22 vs IB 20, p = 0.336) and SOFA (CI 9 vs IB 8, p = 0.217) scores were similar between CI and IB patients. CI patients demonstrated numerically higher PK/PD target attainment rates compared to IB patients at the halfway point (CI 96.6% vs IB 83.9%, p = 0.022) and end (CI 96.6% vs IB 62.5%, p < 0.001) of the dosing interval on Day 1, and at the halfway point (CI 100.0% vs IB 85.7%, p = 0.003) and end (CI 98.2% vs IB 58.9%, p < 0.001) of the dosing interval on Day 3, respectively. WBC count normalisation (CI 4 vs IB 6 days, p = 0.014) and infection-related MV (CI 6 vs IB 9 days, p = 0.038) were shorter for CI patients. Mortality rates (CI 17.7% vs IB 16.0%, p = 0.807) were similar between CI and IB patients. Conclusion: Preliminary results of the BLISS study provide additional PK/PD and clinical outcome data to support the practice of CI administration of beta-lactam antibiotics in critically ill patients with severe sepsis

Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis

This study aims to determine if continuous infusion (CI) is associated with better clinical and pharmacokinetic/pharmacodynamic (PK/PD) outcomes compared to intermittent bolus (IB) dosing in critically ill patients with severe sepsis

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 727 intensive care units of 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific Regions: International Nosocomial Infection Control Consortium (INICC) findings

Short-term peripheral venous catheter-related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available. Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System. We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%). PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries