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

Do we need different predictive equations for the acute and late phases of critical illness? A prospective observational study with repeated indirect calorimetry measurements

BACKGROUND: Predictive equations (PEs) for estimating resting energy expenditure (REE) that have been developed from acute phase data may not be applicable in the late phase and vice versa. This study aimed to assess whether separate PEs are needed for acute and late phases of critical illness and to develop and validate PE(s) based on the results of this assessment. METHODS: Using indirect calorimetry, REE was measured at acute (≤5 days; n = 294) and late (≥6 days; n = 180) phases of intensive care unit admission. PEs were developed by multiple linear regression. A multi-fold cross-validation approach was used to validate the PEs. The best PEs were selected based on the highest coefficient of determination (R2), the lowest root mean square error (RMSE) and the lowest standard error of estimate (SEE). Two PEs developed from paired 168-patient data were compared with measured REE using mean absolute percentage difference. RESULTS: Mean absolute percentage difference between predicted and measured REE was <20%, which is not clinically significant. Thus, a single PE was developed and validated from data of the larger sample size measured in the acute phase. The best PE for REE (kcal/day) was 891.6(Height) + 9.0(Weight) + 39.7(Minute Ventilation)−5.6(Age) – 354, with R2 = 0.442, RMSE = 348.3, SEE = 325.6 and mean absolute percentage difference with measured REE was: 15.1 ± 14.2% [acute], 15.0 ± 13.1% [late]. CONCLUSIONS: Separate PEs for acute and late phases may not be necessary. Thus, we have developed and validated a PE from acute phase data and demonstrated that it can provide optimal estimates of REE for patients in both acute and late phases

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

International Nosocomial Infection Control Consortium report, datasummary of 50 countries for 2010-2015 : Device-associated module

Q3Artículo original1495-1504Background: We report the results of International Nosocomial Infection Control Consortium (INICC) sur-veillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America,Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.Methods:During the 6-year study period, using Centers for Disease Control and Prevention National Health-care Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregateof 3,506,562 days.Results:Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAIrates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associatedpneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples,frequencies of resistance ofPseudomonasisolates to amikacin (29.87% vs 10%) and to imipenem (44.3%vs 26.1%), and ofKlebsiella pneumoniaeisolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27%vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.Conclusions:Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported inCDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the re-duction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC’s main goal tocontinue facilitating education, training, and basic and cost-effective tools and resources, such as stan-dardized forms and an online platform, to tackle this problem effectively and systematically

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

Educational intervention on delirium assessment using confusion assessment method-ICU (CAM-ICU) in a general intensive care unit

Aims and Objectives: To assess intensive care unit nurses’ knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses’ perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. Background: Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. Design: This study, performed in Malaysia, used a single-group pretest–posttest study design to assess the effect of educational interventions and hands-on practices on nurses’ knowledge of intensive care unit delirium and delirium assessment. Methods: Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. Results: There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were “physicians did not use nurses’ delirium assessment in decision-making” and “difficult to interpret delirium in intubated patients”. Conclusions: Educational intervention and hands-on practices increased nurses’ knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. Relevance to Clinical Practice: This study supports existing evidences, indicating that education and training could increase nurses’ knowledge of delirium and delirium assessment. Improving nurses’ knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses’ knowledge become relevant in ICU settings

Validity of predictive equations for estimation of resting energy expenditure among mechanically ventilated critically ill patients: Preliminary findings

Background: Several predictive equations (PEs) have been developed for estimation of energy requirement but very few has been validated among mechanically ventilated critically ill patients in Asian population. Objectives: This study aimed at determining the validity of 14 PEs for energy requirement and identifying metabolic determinants that influence resting energy expenditure (REE). Methods: REE was measured among 90 ventilated critically ill patients by using IndirectCalorimetry (IC). 14 PEs used to estimate patients’ energy requirement was validated against IC using intraclass correlation coefficient (ICC) test. Metabolic determinants assessed were sex, body mass index (BMI), age, patient condition, mNUTRIC score and body cell mass (BCM) status. Recruitment is on-going until sample size of 314 is achieved. Results: In the early phase (≤5days), mean REE for all critically ill patients was 1677±403kcal whereas for obese patients was 1926±438kcal. Penn State equation [PSU(m),2003b] shows highest correlation (ICC=0.635), 95%CI(0.49,0.75), p<0.001 with IC in estimating REE among all critically ill patients. Meanwhile, Harris Benedict Equation (variants) [HBEa(50)x1.25] shows highest correlation (ICC= 0.581), 95%CI(0.12,0.84), p=0.010 in estimating REE among obese patients. There was significant difference in REE by sex, BMI and BCM status during early and late phase (6-10days). During chronic phase (>10days), significant difference in REE was observed in patient condition and BCM status. Conclusion: These preliminary results show that most available validated equations had poor to fair agreement with IC measurement. As such, we opine that it is crucial to determine a reliable PE for assessing energy requirement of Asian critically ill patients

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