Reversal of Feed Intolerance by Prokinetics Improves Survival in Critically Ill Cirrhosis Patients

Association Between Medical Interventions by Doctor Helicopters and Outcomes in Inflammatory Diseases Using a Doctor Helicopter Registry

OBJECTIVE

In Japan, patients with inflammatory diseases are transported from the field by doctor helicopters (DHs). This study aimed to retrospectively investigate the relationship between early medical intervention and outcomes in inflammatory diseases, such as respiratory, urinary tract, and gastrointestinal infections.

METHODS

Using data collected by the Japanese Society for Aeromedical Services from DH base hospitals, cases with a discharge diagnosis of inflammatory diseases were selected. The study evaluated age, sex, request method, vital signs on DH staff contact, medical interventions, and final outcomes (cerebral performance category [CPC] at 1 month postinflammation and survival outcome). Exclusion criteria included cases of cardiac arrest at contact and those with unknown final outcomes. The cases were categorized into 2 groups based on survival or functional outcome (favorable: CPC 1-2; unfavorable: CPC 3-5), and a comparative analysis was conducted between the 2 groups.

RESULTS

Of 41,592 cases in the data set, 785 cases met the inclusion criteria. The mean age was 73.8 years, with 491 male patients, 136 deaths, and 272 cases with poor outcomes. All cases were transported from the scene. Compared with the survival group, the fatal group was older and had poorer consciousness, lower blood pressure, higher rates of airway management, and higher use of vasopressors, glucose, and muscle relaxants, whereas the use of antiemetics was statistically lower. Similarly, compared with the favorable functional outcome group, the poor outcome group was older and had a higher proportion of female patients, poorer consciousness, faster respiratory rate and pulse, lower blood pressure, higher rates of airway management, and higher use of cardiopressors, glucose, and muscle relaxants, with a statistically lower use of antiemetics.

CONCLUSION

In cases where the prehospital condition was severe, medical intervention rates increased, and the outcomes for such patients were poor. Conversely, the presence or absence of antiemetic use may have influenced the outcomes.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns

Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.

Use of prokinetic agents in hospitalised adult patients: A scoping review

BACKGROUND

Gastrointestinal motility is important for adequate uptake of fluids and nutrition but is often impaired in hospitalised patients. Prokinetic agents enhance gastrointestinal motility and are prescribed for many hospitalised patients. In this scoping review, we aimed to systematically describe the body of evidence on the use of prokinetic agents in hospitalised patients. We hypothesised, that the body of evidence would be limited and derive from heterogeneous populations.

METHODS

We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement. We searched Medline, Embase, Epistemonikos and the Cochrane Library for studies assessing the use of prokinetic agents on any indication and outcome in adult hospitalised patients. We used a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence.

RESULTS

We included 102 studies with a total of 8830 patients. Eighty-six studies were clinical trials (84%), and 52 (60%) of these were conducted in the intensive care unit, with feeding intolerance as the main indication. In the non-intensive care setting the indications were wider; most studies assessed use of prokinetic agents before gastroscopy to improve visualisation. The most studied prokinetic agent was metoclopramide (49% of studies) followed by erythromycin (31%). In total 147 outcomes were assessed with only 67% of the included studies assessing patient-centred outcomes, and with gastric emptying as the most frequently reported outcome. Overall, the data provided no firm evidence on the balance between the desirable and undesirable effects of prokinetic agents.

CONCLUSIONS

In this scoping review, we found that the studies addressing prokinetic agents in hospitalised adults had considerable variations in indications, drugs and outcomes assessed, and that the certainty of evidence was judged to be low to very low.