Position statement for critical care nutrition in Hong Kong


Nutrition therapy is an important yet controversial issue in critical care field. There are numerous international guidelines or publications showing different views; therefore it is difficult to practice critical care nutrition in clinical setting. We believed that by providing appropriate and individualized nutrition therapy, patient’s outcome can be improved.

A local position statement was written by the opinion of critical care physicians, intensivists, and dietitians in Hong Kong after reviewing available evidence; with the aim to provide recommendations in nutrition therapy in local critical care setting and to stress the importance of appropriate nutrition therapy. The position statement includes recommendations on the general aspects, enteral nutrition, parenteral nutrition, and nutrition for specific diseases. A flow chart (Figure 1) is constructed to provide a pathway for implementing nutritional therapy in clinical practice. The position statement was endorsed by the Hong Kong Society of Critical Care Medicine (HKSCCM) and the Hong Kong Society of Parenteral and Enteral Nutrition (HKSPEN).

Authors: Li Li Chang, Yue Ho Vincent Lau, Ting Ting Sinn, Siu Pik Peggy Lee, Ka Ming Kwok, Tin Yan Li, Anfernee Yim

Restrictive versus liberal fluid bolus therapy in septic shock children: An evidence-based case report


Fluid bolus therapy (FBT) is one of prime management in early goal-directed therapy (EGDT) to achieve adequate cardiac output. The Fluid Expansion as Supportive Therapy (FEAST) trial, a randomized-clinical trial that was used as an evidence to support fluid resuscitation recommendation in Surviving Sepsis Campaign (SSC) 2020, must be discontinued because of increasing mortality in the group that received higher volume of FBT. We present a case of a 9-year-old girl, 15 kg, came to emergency ward with refractory septic shock and became fluid overload after the second FBT. This proceeding aimed to deliver evidence-based case practice if the comparison between liberal versus restrictive FBT in children with septic shock.

Authors: Irene Yuniar

What is low cardiac output syndrome? A report of two cases


Background: One of the diagnostic criteria of low cardiac output syndrome (LOS) is a cardiac index of less than 1.8 l/min/m2. However, recognition of this syndrome differs among intensivists as to whether or not LOS is synonymous with cardiogenic shock.

Case reports: Here, we present two cases of heart failure who were initially treated with diuretics and subsequently fell into a state of low cardiac output. We treated the patient with low blood pressure with inotropes and the patient with high blood pressure with a vasodilator according to their hemodynamics. We observed that cardiac power was the most significant hemodynamic change in response to these treatments. In this paper, we discuss the definition of LOS and show several criteria for determining LOS.

Conclusions: Broadly, there are several conditions of determining LOS. Even with those conditions, we should still be aware of the pathophysiology of each patient with heart failure. We propose that the definition of LOS should be a state of low cardiac output with corresponding symptoms, even if their blood pressure is high.

Authors: Yuichi Baba, Toru Kubo, Yuri Ochi, Tatsuya Noguchi, Naohito Yamasaki, Hiroaki Kitaoka

Outcomes in severe SARS-CoV-2 patients with liberal oxygenation and steroid therapy - a single centre experience

Real-world reports on outcomes of SARS-CoV-2 infection using higher oxygenation targets along with steroid therapy are lacking. We conducted a retrospective study of patients requiring oxygen support following targets of oxygenation >95% along with steroid therapy. Group 1 with oxygenation through a nasal cannula or Hudson mask, Group 2 oxygenation with venturi system, and Group 3 with high flow nasal oxygen, 35-50 litres; non-invasive ventilation; mechanical ventilation delivering. One hundred and eighteen patients (Group 1 74 patients, Group 2 15 patients, and Group 3 29 patients) were studied. The mean age was 55.7 years and most were male (n=77). One hundred and fourteen received dexamethasone or methylprednisolone. Most (88.3%) had at least one pre-existing chronic medical illness. Overall mortality was 22.8% (n=27). Group 3 had the highest mortality (75.9%) followed by Group 2 (26.7%) and Group 1 (1.35%). Our observation raises the query if a higher target of oxygenation for non-mechanical ventilated patients coupled with steroid therapy is beneficial.

Authors: Priyadarshini Varadaraj, Sowmya Gopalan, Aiswarya M. Nair, Lakshmi Marappa, Vaasanthi Rajendran, Viswanathan Pandurangan, Sudha Madhavan, Rajkumar Mani, Emmanuel Bhaskar

Restrictive fluid and fluid removal approach in diabetic ketoacidosis with septic AKI: A case report


Diabetic ketoacidosis is a life-threatening complication that requires a rapid restoration of intravascular volume usually with aggressive administration of intravenous fluid with 0.9% sodium chloride as recommended by the American Diabetes Association. We report a 50-year-old obese female patient with a history of diabetes mellitus (DM) since 20 years ago and routinely using insulin. She experienced dyspnea and presumably was caused by diabetic ketoacidosis. The patient was given fluid resuscitation with normal saline, but the dyspnea did not resolve and the work of breathing increased further, so the patient was intubated and admitted to the intensive care unit. Aggressive fluid resuscitation carries potential adverse effects such as hyperchloremic metabolic acidosis, interstitial multi-organ edema, and increased incidence of acute kidney injury. The first day of ICU treatment, positive cumulative fluid balance occurred and fluid removal was indicated. Fluid removal using diuretic or ultrafiltration is a part of the treatment of organ congestion and fluid overload after the initial phase of shock resuscitation to achieve negative fluid balance. This case showed that restricted fluid and fluid removal improve the patient outcome, especially in diabetic ketoacidosis and septic AKI patients.

Authors: Elvia AS, Mayang Indah Lestari, Yohannes WH George

Invasive mechanical ventilation during the first wave of COVID-19: Management and outcomes


Objective: To describe demographics, clinical, and respiratory mechanics (including ventilatory management details) of patients admitted to the Intensive Care Unit (ICU) with severe COVID-19 and to evaluate the effectiveness of gas exchange variables, ventilatory parameters, and ICU illness severity scores in predicting 28-day mortality.

Design: Single-center retrospective cohort study.

Setting: Portuguese medical-surgical ICU.

Patients: Adults sequentially admitted to the ICU, from March 18 to May 12, 2020, with critical COVID-19 requiring invasive mechanical ventilation (IMV) for over 48 hours.

Interventions: None, due to study design.

Measurements and results: Data regarding positioning, positive end-expiratory pressure (PEEP), driving pressure, static lung compliance, and lowest daily arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio throughout the first 5 days of ICU admission were collected from daily ventilatory assessment charts. The median ICU length of stay was 11.3 days and median IMV duration was 9.5 days. The 28-day mortality was 12.1%. When comparing non-survivors and survivors, significant differences were found regarding Simplified Acute Physiology Score (SAPS) II (48.5, IQR 14.0 vs. 32.0, IQR 11.0, p=0.004), PaO2/FiO2 ratio before endotracheal intubation (101.3, IQR 22.5 vs. 174.1, IQR 9.5, p=0.01) and throughout ICU stay. Over 90% of patients were submitted to prone positioning. Use of low PEEP levels and maintenance of low driving pressures in patients whose overall compliance was low as possible.

Conclusions: Significant differences were found regarding SAPS II and PaO2/FiO2 ratios between survivors and non-survivors, eliciting further investigation as potential mortality predictors. With the second wave of the pandemic taking shape, sharing previous experience is crucial to further coordinate efforts internationally.

Authors: Mafalda Aguiar Mourisco, Filipa Resende Brochado, Filipe Silva Machado, Diana Moreira Dias, Ricardo Pinho, Paulo Reis Rodrigues