Critical care : the official journal of the Critical Care Forum
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Nutritional support is generally considered an essential component in the management of critically ill patients. The existing guidelines advocate early enteral nutrition, with the optimal timing for the addition of parenteral nutrition to insufficient enteral feeding being the subject of transatlantic controversy. The unphysiologic intervention of artificial nutrition in critically ill patients, however, may evoke complications and side effects. ⋯ The question whether artificial nutrition in critical illness improves or worsens outcome as compared with starvation has so far not been adequately addressed. This paper provides a critical analysis of the existing literature on ICU nutrition, highlighting important methodological shortcomings of many trials and meta-analyses and underlining the urgent need for high-quality research in this field. Recent adequately designed randomized controlled trials suggest that trophic enteral feeding during the first week of critical illness is as good as full enteral feeding and that early addition of parenteral nutrition to insufficient enteral nutrition does not provide any benefit and worsens morbidity.
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Hypotension in septic patients results from hypovolemia, vasodilatation and hyporeactivity to vasoconstrictors, such as angiotensin II. The AT1 receptor-associated protein 1 (Arap1) is expressed in vascular smooth muscle cells and increases the surface expression of the AT1-receptor in vitro. We hypothesized that dysregulation of Arap1 may contribute to vascular hyporeactivity to angiotensin II during endotoxemia. ⋯ Our data suggest that down-regulation of Arap1 expression during sepsis contributes to the development of hypotension by causing reduced vascular sensitivity to angiotensin II.
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Hydroxyethyl starch (HES) is a commonly used colloid in critically ill patients. However, its safety has been questioned in recent studies and meta-analyses. ⋯ The most important question, whether or not HES may be harmful when it is limited to immediate haemodynamic stabilisation, cannot be answered yet in the absence of any study sufficiently addressing this question. In order to overcome the limitations of most of the previous studies, we now suggest an algorithm emphasising the strict indication of HES. Additionally, we give a list of suggestions that should be adequately considered in any prospective RCT in the field of acute volume resuscitation in critically ill patients.
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Despite the universal prescription of sedative drugs in the intensive care unit (ICU), current practice is not guided by high-level evidence. Landmark sedation trials have made significant contributions to our understanding of the problems associated with ICU sedation and have promoted changes to current practice. We identified challenges and limitations of clinical trials which reduced the generalizability and the universal adoption of key interventions. We present an international perspective regarding current sedation practice and a blueprint for future research, which seeks to avoid known limitations and generate much-needed high-level evidence to better guide clinicians' management and therapeutic choices of sedative agents.
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Clinical Trial Observational Study
Screening and risk factors of exocrine pancreatic insufficiency in critically ill adult patients receiving enteral nutrition.
Malnutrition is a frequent problem associated with detrimental clinical outcomes in critically ill patients. To avoid malnutrition, most studies focus on the prevention of inadequate nutrition delivery, whereas little attention is paid to the potential role of exocrine pancreatic insufficiency (EPI). In this trial, we aim to evaluate the prevalence of EPI and identify its potential risk factors in critically ill adult patients without preexisting pancreatic diseases. ⋯ More than 50% of critically ill adult patients without primary pancreatic diseases had EPI, and nearly one-fifth of them had severe EPI. The risk factors for EPI included shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis.