Critical care : the official journal of the Critical Care Forum
-
The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. ⋯ Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.
-
The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact. This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery. ⋯ Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period. With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.
-
Observational Study
Current clinical nutrition practices in critically ill patients in Latin America: a multinational observational study.
Malnutrition in critically ill adults in the intensive care unit (ICU) is associated with a significantly elevated risk of mortality. Adequate nutrition therapy is crucial to optimise outcomes. Currently, there is a paucity of such data in Latin America. Our aims were to characterise current clinical nutrition practices in the ICU setting in Latin America and evaluate whether current practices meet caloric and protein requirements in critically ill patients receiving nutrition therapy. ⋯ In the ICU setting in Latin America, malnutrition was highly prevalent and caloric intake failed to meet targeted energy delivery in 40% of critically ill adults receiving nutrition therapy. Supplemental administration of PN was associated with improved energy and protein delivery; however, PN use was low. Collectively, these findings suggest an opportunity for more effective utilisation of supplemental PN in critically ill adults who fail to receive adequate nutrition from EN alone.
-
Observational Study
Markers of acute kidney injury in patients with sepsis: the role of soluble thrombomodulin.
Endothelial activation and damage occur early during sepsis, with activated coagulopathy and playing a major role in the pathophysiology of sepsis-induced acute kidney injury (AKI). The aim of this study was to compare the various biomarkers of endothelial injury with the biomarkers of coagulation and inflammation and to determine a significant predictor of AKI in patients with sepsis. ⋯ Endothelial biomarkers were significantly changed in the sepsis patients with AKI. Particularly, sTM was an independent predictive biomarker for the development of AKI that outperformed other coagulation and inflammation biomarkers as well as organ function in patients with sepsis.