A european, multicenter, observational study to assess the value of gastric-to-end tidal PCO2 difference in predicting postoperative complications

Diarrhoea in the critically ill is common, associated with poor outcome, and rarely due to Clostridium difficile

Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15–38%. Many factors may cause diarrhoea, including Clostridium difficile, drugs (e.g. laxatives, antibiotics) and enteral feeds. Diarrhoea impacts on patient dignity, increases nursing workload and healthcare costs, and exacerbates morbidity through dermal injury, impaired enteral uptake and subsequent fluid imbalance. We analysed a cohort of 9331 consecutive patients admitted to a mixed general intensive care unit to establish the prevalence of diarrhoea in intensive care unit patients, and its relationship with infective aetiology and clinical outcomes. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70–2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Our findings suggest non-infective causes of diarrhoea in ICU predominate and pathophysiology of diarrhoea in critically ill patients warrants further investigation.

Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients

OBJECTIVE

Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients.

METHODS

Prospective cohort study with 92 septic patients, age ≥ 18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed.

RESULTS

The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression.

CONCLUSION

Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems

PURPOSE

Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options.

METHODS

The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology.

RESULTS

Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided.

CONCLUSIONS

State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes.

Splanchnic vasoregulation after major abdominal surgery in pigs

BACKGROUND

Unrecognized reduction of blood supply to intestinal organs is associated with significant postoperative morbidity in abdominal surgery. The aim of this study was to determine whether--in the absence of hypovolemia--intestinal hypoperfusion as a result of blood flow redistribution occurs after abdominal surgery.

METHODS

Standardized operative trauma was induced in 14 healthy pigs. Systemic, regional, and local blood flow, intestinal and gastric intraluminal-to-end-tidal pCO(2) gradients representing mucosal perfusion, and oxygen transport variables were measured for 10 postoperative hours. Normovolemia was maintained using continuous infusion of Ringer's lactate and additional boluses of colloids in response to blood pressure, pulmonary wedge pressure, and urinary output.

RESULTS

Postoperative blood flow was significantly increased in the celiac trunk (76% increase [percentage of baseline flow], p = 0.003) and the hepatic (136% increase, p = 0.002) and splenic (36% increase, p = 0.025) arteries. Blood flow was significantly decreased in the mesenteric artery (25% decrease, p = 0.007) and portal vein (13% decrease, p = 0.028). Carotid and renal artery blood flow remained unchanged.

CONCLUSIONS

Maintenance of normovolemia is insufficient to protect from intestinal hypoperfusion after abdominal surgery. Postoperative redistribution of cardiac output results in decreased intestinal and increased hepatic and splenic arterial blood flow.

Intraoperative gastric tonometric examinations in children and infants with a new probe, combined with measurement of the endtidal PCO2

BACKGROUND

Important progress relating to the early prediction of postoperative complications was recently achieved through the combined use of endtidal PCO(2) (P(ET)CO(2)) and gastric tonometry. The aim of this article was to present results obtained with a new tonometric instrument, proving its feasibility and extending its use to the control of anesthetized infants and children.

METHODS

The new tonometric probe, which is balloon free, consists basically of silicone rubber tubing. The room air initially inside the tubes of the probe equilibrates with the PCO(2) of the body cavity throughout its full length. The PCO(2) content of the gastric cavity (P(g)CO(2)) and simultaneously P(ET)CO(2) were measured with a microcapnograph. A total of 108 measurements were performed intraoperatively on 25 infants and young children operated on at the Surgical Unit of the Department of Pediatrics. The patients were divided into elective surgery cases <2 years of age, group I; elective surgery cases >2 years of age, group II; and acute surgery cases, independently of age, group III. To examine the degree of agreement between the measurements, Pearson's correlation coefficients were determined and Bland-Altman analysis was performed. A mixed model repeated measurements anova was used to compare the differences between the groups.

RESULTS

P(ET)CO(2) and P(g)CO(2) for groups I and II were nearly identical, and statistically not significantly different (mean difference 0.10 mmHg and 0.85 mmHg, P = 0.96 and 0.45, respectively), whereas the corresponding data for group III differed significantly from those for groups I and II (P = 0.03 and 0.001, respectively). On Bland-Altman analysis, the bias value for groups proved to be statistically significantly different (P = 0.001).

CONCLUSIONS

The tested new probe worked very well in small children. The clinical implications of the large gaps found between P(ET)CO(2) and P(g)CO(2) values in acutely ill children and children undergoing elective operations must be investigated further.

Rectal lactate levels in endoluminal microdialysate during routine coronary surgery

The aim of this prospective study was to determine the feasibility of intestinal endoluminal microdialysis as a new method for clinical monitoring of the adequacy of splanchnic perfusion in the large bowel. A microdialysis catheter for continuous lactate, glycerol, glucose and pyruvate measurements attached to a tonometric catheter was placed into the lumen of the recto-sigmoid junction prior to surgery in 13 patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB). Lactate was also measured in blood and muscle. CPB was associated with a 10-fold increase in luminal lactate from 0.16 (0.01) to 1.67 (0.38) mmol x l(-1) (p < 0.001). Muscular lactate increased from baseline levels 1.20 (0.21) to 1.77 (0.36) mmol x l(-1) during CPB (p = 0.01), but the muscular lactate-pyruvate ratio remained unchanged. Arterial lactate increased only slightly from 0.9 (0.05) to 1.1 (0.06) mmol x l(-1) (p = 0.027) during CPB. Increased lactate concentrations in the large bowel during CPB are suggestive of local lactate production consistent with impaired oxygen delivery. Intestinal endoluminal microdialysis is a potential clinically applicable method for monitoring intestinal metabolism. Combined with tonometry, microdialysis provides the opportunity to monitor both circulation and metabolism in the rectal mucosa.