The Addition of Trickle Feeds Reduces the Complications Associated with Parenteral Nutrition

Background: “Trickle feeds” are frequently added to patients receiving parenteral nutrition on the assumption that providing small volumes of enteral nutrition reduces the complications associated with parenteral nutrition. This hypothesis, however, has not been tested. Objective: The aim of this study was to compare the incidence of ventilator-associated pneumonia and the Standardized Mortality Ratio in critically ill ICU patients receiving parenteral nutrition alone as compared to parenteral nutrition together with trickle feeds. Design: This was a non-randomized cohort study. The incidence of ventilator-associated pneumonia and the Standardized Mortality Ration was compared in critically ill ICU patients with an acute abdominal processes who had received at least 3 days of parenteral nutrition or parenteral nutrition together with trickle feeds. The diagnoses of pneumonia was made by protected specimen bruch sampling. Results: Thirty two patients received parenteral nutrition alone and 34 parenteral nutrition together with trickle feeds. The patients receiving trickle feeds had a loweer incidence of confirmed bacterial pneumonia (8 vs 28%; p=0.05) and a trend towards a lower hospital mortality. The Standardized Mortality Ratio was 1.4 in the patients receiving parenteral nutrition alone and 0.85 in patients receiving trickle feeds together with parenteral nutrition; a 44% reduction in mortality. Conclusion: This study suggests that the addition of “trickle” feeds to parenteral nutrition reduces infective complications and may reduce hospital mortality.


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Assessement of Change in Body Water By Multiple Frequency Bioelectrical Impedance in Patients Undergoing Cardiopulmonary Bypass

Objective: To evaluate the relationship between changes in body bioelectrical impedance (BI) at 1, 50, 100 kHz and fluid balance, as an index of body water changes, in patients undergoing cardiopulmonary bypass.
Design: Descriptive, correlative.
Setting: Intensive Care Unit of a cardiac center Patients: Twenty male patients, before and after elective coronary artery bypass graft surgery with cardiopulmonary bypass.
Interventions: None.
Measurements: Whole body bioelectrical impedance using multiple frequency bioelectrical impedance (Dietosystem, Italy) at multiple frequencies (1, 50, 100 kHz) was conducted preoperatively and three times during the 24 hour postoperative period. The volume of body water compartment was calculated using Guricci’s formula. The calculated fluid balances uncorrected for insensible water losses were measured from fluid intake and output.
Findings: In 24 hours after surgery calculated total body water (TBW), extracellular water (ECW), and intracellular water (ICW) increased by 16.0%, 20.7%, and 13.0%, respectively, but the values were within desirable ranges. There was no correlation between TBW changes measured by MFBIA and calculated fluid balance.
Conclusions: The current study indicates that changes of body water compartment occur during 24 hours after CABG. Calculated ICW increases within 24 hours after CABG.


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Pro- and Anti-Infl ammatory Balance of Septic Patients is Associated with Severity and Outcome

Purpose: To study infl ammatory profile in patients with sepsis, severe sepsis and septic shock with regards to organ dysfunction and outcome, and to identify a pattern associated with more catastrophic course of illness, organ failure and risk of death. Material and methods: Twenty-nine consecutive patients with sepsis admitted to a medical Intensive Care Unit of a tertiary university hospital (November 2002-December 2003). Plasmatic levels of interleukin-6 (IL-6) and interleukin-10 (IL- 10) as pro-infl ammatory and anti-infl ammatory markers were measured at baseline, 12, 24 and 48 hours of evolution. Results: There is a positive association between higher levels of IL-6 and severity of the septic process, organ dysfunctions and risk of death, statistically signifi cant at anytime (at baseline, 12, 24 and 48 hours, p <0.05). Higher IL-6/IL-10 ratios associate signifi cantly with risk of death at 24 hours (RR=1.45 if higher or equal to the median). Conclusions: Plasmatic biomarkers measurement during the initial phase of sepsis may help to individualize therapy. An evaluation at 24 h based on IL-6/IL-10 ratio may anticipate a more aggressive infl ammatory profi le. These patients would specially benefi t from immunomodulating therapies to improve survival.


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Use and Understanding of Therapeutic Hypothermia in Developing Countries

Purpose: The use of therapeutic hypothermia (TH) has increased in the treatment of comatose victims of cardiac arrest, traumatic brain injury, refractory dysrhythmias, neonatal encephalopathy and asphyxia, near-drowning and hemorrhagic shock. The purpose of this study was to ascertain the level of understanding of TH use for comatose victims of cardiac arrest among healthcare providers in two developing countries. Methods: A 22-question survey was administered to physicians, nurses, and other health professionals who attended two large emergency medicine and critical care meetings in Indonesia and Mexico. The questionnaire included socio-demographic characteristics of the respondents. Specifi c questions regarding TH awareness and its use were included, as well as questions examining familiarity with the current recommendations from International Liaison Committee on Resuscitation (ILCOR) Results: Two hundred and sixty-six surveys were collected from the two countries. Of all respondents, 15.54% had used TH: 37.8% were nurses and 31.58% physicians (ñ =0.012). TH was used most frequently administered in the coronary care unit and the emergency department (55% and 45%, ñ =0.005). Eight percent of all respondents had TH protocols established at their institutions, mostly by nursing personnel (80% ñ =0.009). Practitioners reported they were not familiar with the ILCOR guidelines (97% of the respondents from Mexico and 87% of the respondents from Indonesia (ñ =0.009)). Among those using TH, active rewarming was used by 71% of respondents queried in Indonesia as compared with 38% of respondents surveyed in Mexico (ñ =0.001). Conclusions: TH appears underutilized in our sample of practitioners from two developing countries. Clinicians in these countries are not familiar with ILCOR TH guidelines. Therapeutic hypothermia is certainly practical in most clinical settings and programs aimed at educating practitioners about TH are needed in developing countries to improve neurological outcome in comatose victims of cardiac arrest.


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