Parenteral nutrition in the intensive care unit: cautious use improves outcome.

Critical illness is characterised by nutritional and metabolic disorders, resulting in increased muscle catabolism, fat-free mass loss, and hyperglycaemia. The objective of the nutritional support is to limit fat-free mass loss, which has negative consequences on clinical outcome and recovery. Early enteral nutrition is recommended by current guidelines as the first choice feeding route in ICU patients. However, enteral nutrition alone is frequently associated with insufficient coverage of the energy requirements, and subsequently energy deficit is correlated to worsened clinical outcome. Controlled trials have demonstrated that, in case of failure or contraindications to full enteral nutrition, parenteral nutrition administration on top of insufficient enteral nutrition within the first four days after admission could improve the clinical outcome, and may attenuate fat-free mass loss. Parenteral nutrition is cautious if all-in-one solutions are used, glycaemia controlled, and overnutrition avoided. Conversely, the systematic use of parenteral nutrition in the ICU patients without clear indication is not recommended during the first 48 hours. Specific methods, such as thigh ultra-sound imaging, 3rd lumbar vertebra-targeted computerised tomography and bioimpedance electrical analysis, may be helpful in the future to monitor fat-free mass during the ICU stay. Clinical studies are warranted to demonstrate whether an optimal nutritional management during the ICU stay promotes muscle mass and function, the recovery after critical illness and reduces the overall costs.

Prospective monitoring of cefepime in intensive care unit adult patients

Rapport de synthèse :Le céfépime a été associé à un taux de mortalité supérieur à celui des autres bêta-lactamines chez les patients traités pour un sepsis sévère. Une des hypothèses avancées pour expliquer ces échecs thérapeutiques sont de possibles effets secondaires cachés (par ex. neurologiques) ou des paramètres pharmacocinétiques/pharmacodynamiques (PK/PD) inadaptés. Le présent travail a étudié cette problématique en mesurant prospectivement la pharmacocinétique du céfépime chez 21 patients consécutifs hospitalisés aux soins intensifs adultes (SIAD) pour une pneumonie nosocomiale. La population étudiée avec un âge médian 55,1 ans, a reçu par voie intraveineuse du céfépime à raison de 2 g toutes les 12 heures pour une clairance de la créatinine (Clcr)>50 mI/ min, et 2 g toutes les 24 heures ou 36 heures pour une Clcr<50 ml /min. Les taux plasmatiques de céfépime ont été mesurés à plusieurs reprises avant et après administration du médicament après la lèoe dose et à l'état d'équilibre par chromatographie en phase liquide à haute pression. Les taux plasmatiques ont considérablement varié entre les patients. Cent pour cent (21/21) des patients ont eu une durée appropriée d'antibiothérapie avec des taux plasmatiques supérieures à la CMI du céfépime (T>CMI>50%) pour les agents pathogènes retrouvés dans cette étude (CMI<4 mg/I), mais seulement 45-65% d'entre eux ont eu une couverture appropriée pour les agents pathogènes potentiels présentant une CMI> 8 mg/I pour le céfépime. Deux patients avec une insuffisance rénale (Clcr<30 ml/min) ont présenté des symptômes compatibles avec une épilepsie non-convulsive (état confusionnel et myoclonies) attribuée dans un 2ème temps à une toxicité du céfépime après que les taux plasmatiques aient été communiqués aux soignants qui ont suspendu l'antibiothérapie avec disparition des symptômes. Les résultats de cette étude empirique confirment l'existence d'effets secondaires cachés et de paramètres PK/PD inappropriés (pour les agents pathogènes ayant des CMI de limite supérieure) dans notre population de SIAD. En outre, ils mettent en évidence une fenêtre thérapeutique efficace pour une posologie de céfépime de 2 g toutes les 12 heures chez les patients ayant une Clcr>50 ml/min infectés par des pathogènes avec des CMI pour le céfépime <4 mg/I. Les échecs thérapeutiques constatés dans cette étude sont probablement liés à des taux sériques inadaptés, résultant de la difficulté de prescription dans les situations cliniques complexes. Dans ce contexte, un prompt dosage plasmatique du céfépime doit être considéré en cas de diminution de la Clcr ou en présence de CMI élevées.

Pharmaceutical care in an inpatient pediatric intensive care unit: an international multicentric study

Introduction Pediatric intensive care patient represent a population athigh risk for drug-related problems. Our objective is to describe drugrelated problems and intervention of four decentralized pharmacists inpediatric and cardiac intensive care unit.Materials & Methods Multicentric, descriptive and prospectivestudy over a six-month period (August 1st 2009-January 31st 2010).Drug-related problems and clinical interventions were compiled infour pediatric centers using a tool developed by the Socie´te´ Franc¸aisede Pharmacie Clinique. Data concerning patients, drugs, intervention,documentation, approval (if needed), and estimated impact werecompiled. The four pharmacists participating were from Belgium (B),France (F), Quebec (Q) and Switzerland (S).Results A total of 996 interventions were collected: 129 (13%) in B,238 (24%) in F, 278 (28%) in Q and 351 (35%) in S. These interventionstargeted 269 patients (median 22 month-old, 52% male): 69(26%) in B, 88 (33%) in F, 56 (21%) in Q and in S. These data werecollected during 28 non consecutive days in the clinical unit in B, 59days in F, 42 days in Q and 63 days in S. The main drug-relatedproblems were inappropriate administration technique (293, 29%),untreated indication (254, 25%) and supra therapeutic dosage (106,11%). The pharmacist's interventions concerned mainly administrationmode optimization (223, 22%), dose adjustment (200, 20%) andtherapeutic monitoring (164, 16%). The three major drug classesleading to interventions were anti-infectives for systemic use (233,23%) and alimentary tract and metabolism drugs (218, 22%). Interventionsconcerned mainly residents and all clinical staff (209, 21%).Among the 879 (88%) interventions requiring a physician's approval,731 (83%) were accepted. Interventions were considered as having amoderate (51%) or major (17%) clinical impact. Among the interventionsprovided, 10% were considered to have an economicalpositive impact. Differences and similarities between countries willbe presented at the poster session.Discussion & Conclusion Decentralized pharmacist at patient bedsideis a pre-requisite for pharmaceutical care. There are limitedstudies comparing the activity of clinical pharmacists betweencountries. This descriptive study illustrates the ability of clinicalpharmacist to identify and solve drug-related problems in pediatricintensive care unit in four different francophone countries.

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Parental attitude towards alternative medicine in the paediatric intensive care unit.

The interest in alternative medicine (AM) is growing. In the USA and Canada, studies showed that 34% of adults and 11% of children use AM. In a prospective cohort study, we investigated the interest in AM among parents of critically ill children in the paediatric Intensive Care Unit (ICU) of a university hospital. From January 1996 to April 1997, we distributed questionnaires to the parents of critically ill children. These strictly anonymous questionnaires were completed at home and returned by mail. Exclusion criteria were short ( < 1 day) or repeated hospitalizations, and insufficient proficiency of the German language. The inclusion criteria were fulfilled by 591 patients; 561 received the questionnaire (95%) and 289 (52%) were returned. Of the respondents, 70% would appreciate AM as a complementary therapy on the ICU, 23% found AM equally or more important than conventional medicine whereas only 7% regarded AM as unimportant. On the ICU, 18% used AM; surprisingly 41% of them did not discuss it with physicians or nurses. An additional 21% would have liked to use AM, but did not do so. Typically, AM-users administered AM also at home to their children and themselves. Their children were however, older.CONCLUSIONS: A substantial proportion of parents used measures of alternative medicine in the intensive care unit, or would have like to do so. However, few had the confidence to discuss this wish with the medical personal. This suggests that alternative medicine is of great interest, even on an intensive care unit. Nevertheless, discussion about alternative medicine seems to be taboo in doctor-patient relations.

Prospective monitoring of cefepime in intensive care unit adult patients.

INTRODUCTION: Cefepime has been associated with a greater risk of mortality than other beta-lactams in patients treated for severe sepsis. Hypotheses for this failure include possible hidden side-effects (for example, neurological) or inappropriate pharmacokinetic/pharmacodynamic (PK/PD) parameters for bacteria with cefepime minimal inhibitory concentrations (MIC) at the highest limits of susceptibility (8 mg/l) or intermediate-resistance (16 mg/l) for pathogens such as Enterobacteriaceae, Pseudomonas aeruginosa and Staphylococcus aureus. We examined these issues in a prospective non-interventional study of 21 consecutive intensive care unit (ICU) adult patients treated with cefepime for nosocomial pneumonia. METHODS: Patients (median age 55.1 years, range 21.8 to 81.2) received intravenous cefepime at 2 g every 12 hours for creatinine clearance (CLCr) >or= 50 ml/min, and 2 g every 24 hours or 36 hours for CLCr < 50 ml/minute. Cefepime plasma concentrations were determined at several time-points before and after drug administration by high-pressure liquid chromatography. PK/PD parameters were computed by standard non-compartmental analysis. RESULTS: Seventeen first-doses and 11 steady states (that is, four to six days after the first dose) were measured. Plasma levels varied greatly between individuals, from two- to three-fold at peak-concentrations to up to 40-fold at trough-concentrations. Nineteen out of 21 (90%) patients had PK/PD parameters comparable to literature values. Twenty-one of 21 (100%) patients had appropriate duration of cefepime concentrations above the MIC (T>MIC >or= 50%) for the pathogens recovered in this study (MIC <or= 4 mg/l), but only 45 to 65% of them had appropriate coverage for potential pathogens with cefepime MIC >or= 8 mg/l. Moreover, 2/21 (10%) patients with renal impairment (CLCr < 30 ml/minute) demonstrated accumulation of cefepime in the plasma (trough concentrations of 20 to 30 mg/l) in spite of dosage adjustment. Both had symptoms compatible with non-convulsive epilepsy (confusion and muscle jerks) that were not attributed to cefepime-toxicity until plasma levels were disclosed to the caretakers and symptoms resolved promptly after drug arrest. CONCLUSIONS: These empirical results confirm the suspected risks of hidden side-effects and inappropriate PK/PD parameters (for pathogens with upper-limit MICs) in a population of ICU adult patients. Moreover, it identifies a safety and efficacy window for cefepime doses of 2 g every 12 hours in patients with a CLCr >or= 50 ml/minute infected by pathogens with cefepime MICs <or= 4 mg/l. On the other hand, prompt monitoring of cefepime plasma levels should be considered in case of lower CLCr or greater MICs.

Pédiatrie. 1. Comment favoriser le développement de l'oralité en néonatologie [Pediatrics. How can we improve oral feeding in the neonatal intensive care unit?].

Preterm or sick neonates are frequently hampered in establishing a safe and efficient oral feeding. This can delay hospital discharge and impact on parent-child bonding, growth or neurodevelopment. Recent researches identified a pattern of interventions that could allow to reduce these troubles and to shorten hospital stays.

Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome.

BACKGROUND: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II. METHODS: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days. RESULTS: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 ± 16 years, SAPS II score 39 ± 16, SOFA score 7.6 ± 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for ≤ 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality. CONCLUSIONS: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.

Réactualisation de la douzième conférence de consensus de la Société de réanimation de langue française (SRLF) : infections liées aux cathéters veineux centraux en réanimation [Updating of the 12th consensus conference of the Société de Réanimation de langue française (SRLF) : catheter related infections in Intensive Care unit]

Concerning catheter-related infections, many studies have been conducted until the last consensus conference of the Sociétéde réanimation de langue française (SRLF) in 1994. This text is the synthesis of the considerable amount of work performed by the experts of the society to review recent studies. The experts' texts as well as extensive bibliography are available at http://www.srlf.org.

Sources d'exposition aux phtalates dans une unité de soins néonatals [Phthalate exposure in the neonatal intensive care unit].

There are growing concerns on long-term health consequences, notably on fertility rates, of plasticizers such as phthalates. While di(2-ethylhexyl)phthalate (DEHP) is currently used in several medical devices, newborns in the neonatal intensive care unit are both more exposed and more vulnerable to DEHP. The objectives of this study were to identify, count, and describe possible sources of DEHP in a neonatal care unit. Our method consisted in the listing and the inspection of the information on packaging, complemented by contact with manufacturers when necessary. According to the results, 6% of all products and 10% of plastic products contained some DEHP; 71% of these involved respiratory support devices. A vast majority of the items showed no information on the content of DEHP. Further research is needed, particularly to determine the effects of such an early exposure and to study and develop safer alternatives.

Prospective study of the barriers to nutritional support in a paediatric intensive care unit : P16

Introduction and aim: Children hospitalised in a paediatric intensive care unit (PICU) are mainly fed by nutritional support (NS) which may often be interrupted. The aims of the study were to verify the relationship between prescribed (PEI) and actual energy intake (AEI) and to identify the reasons for NS interruption. Methods: Prospective study in a PICU. PEI and AEI from day 1 to 15, type of NS (enteral, parenteral, mixed), position of the feeding tube, interruptions in NS and reasons for these were noted. Inter - ruptions were classified in categories of barriers and their frequency and duration were analysed. Results: Fifteen children (24 ± 25.2 months) were studied for 84 days. The NS was exclusively enteral (69%) or mixed (31%). PEI were significantly higher than AEI (54.7 ± 32.9 vs 49.2 ± 33.6 kcal/kg, p = 0.0011). AEI represented 93% of the PEI. Ninety-eight interruptions were noted and lasted 189 h, i.e. 9.4% of the evaluated time. The most frequent barriers were nursing procedures, respiratory physiotherapy and unavailability of intravenous access. The longest were caused by the necessity to stop NS for surgery or diagnostic studies, to treat burns or to carry out medical procedures. Conclusion: AEI in PICU were inferior by 7% to PEI, considerably lower than in adult studies. Making these results available to medical staff for greater anticipation and compensation could reduce NS interruptions. Starving protocols should be reconsidered.