A new high protein-to-energy enteral formula with a whey protein hydrolysate to achieve protein targets in critically ill patients: a prospective observational tolerability study

OBJECTIVES

Current guidelines and expert recommendations stress the need to implement enteral feeds with a higher protein-to-energy ratio to meet protein requirements as recommended while avoiding gastrointestinal side effects and energy overfeeding in ICU patients.

MATERIALS AND METHODS

Prospective tolerability study in 18 critically ill patients with a high protein formula (high protein-to-energy (HP:E) formula = Fresubin® Intensive; HPG) compared to a contemporary matched conventional therapy group (CTG). The primary outcome was GI intolerance defined as ≥300 ml daily gastric residual volume (GRV), vomiting, or diarrhea on days 1 and 2. Secondary outcomes were the percentage of patients reaching their protein target on day 4 and overall protein intake.

RESULTS

Groups were comparable regarding demographic characteristics, disease severity, organ failures, mechanical ventilation, and NUTRIC score at baseline. Eighteen patients completed the 4-day feeding period. The number of events of GRV of ≥300 ml/day was equal in both groups (33.3%). The incidence of diarrhea and vomiting was low in the HPG (two patients concerned). EN did not need to be discontinued due to intolerance in any group. Seventy-two percent of patients reached protein targets ≥1.3 g/kgBW/d within 4 days after initiation of enteral feeding, which was superior to the CTG (33%). Post-hoc testing showed group differences of protein intake between HPG and CTG were significant at t = 72 h and t = 96 h. Energy targets were met in both groups.

CONCLUSION

The HP:E formula containing 33% whey protein hydrolysate is well tolerated in this tolerability study. Due to the HP:E ratio protein targets can be reached faster. Larger randomized trials are needed to confirm preliminary results.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02678325. Registered 2 May 2016.

Comparison of propofol and dexmedetomidine infused overnight to treat hyperactive and mixed ICU delirium: a protocol for the Basel ProDex clinical trial

BACKGROUND/OBJECTIVES

Delirium is a neurobehavioural disturbance that frequently develops particularly in the intensive care unit (ICU) population. It was first described more than half a century ago, where it was already discovered as a state that might come along with serious complications such as prolonged ICU and hospital stay, reduced quality of life and increased mortality. However, in most cases, there is still lack of proof for causal relationship. Its presence frequently remains unrecognised due to suggested predominance of the hypoactive form. Furthermore, in the general ICU population, it has been shown that the duration of delirium is associated with worse long-term cognitive function. Due to the multifactorial origin of delirium, we have several but no incontestable treatment options. Nonetheless, delirium bears a high burden for patient, family members and the medical care team.The Basel ProDex Study targets improvement of hyperactive and mixed delirium therapy in critically ill patients. We will focus on reducing the duration and severity of delirium by implementing dexmedetomidine into the treatment plan. Dexmedetomidine compared with other sedatives shows fewer side effects representing a better risk profile for delirium treatment in general. This could further contribute to higher patient safety.The aim of the BaProDex Trial is to assess the superiority of dexmedetomidine to propofol for treatment of hyperactive and mixed delirium in the ICU. We hypothesise that dexmedetomidine, compared with propofol administered at night, shortens both the duration and severity of delirium.

METHODS/DESIGN

The Basel ProDex Study is an investigator-initiated, one-institutional, two-centre randomised controlled clinical trial for the treatment of delirium with dexmedetomidine versus propofol in 316 critically ill patients suffering from hyperactive and mixed delirium. The primary outcome measure is delirium duration in hours. Secondary outcomes include delirium-free days at day 28, death at day 28, delirium severity, amount of ventilator days, amount of rescue sedation with haloperidol, length of ICU and hospital stay, and pharmaceutical economic analysis of the treatments. Sample size was estimated to be able to show the superiority of dexmedetomidine compared with propofol regarding the duration of delirium in hours. The trial will be externally monitored according to good clinical practice (GCP) requirements. There are no interim analyses planned for this trial.

ETHICS AND DISSEMINATION

This study will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonization- Good Clinical Practice (ICH-GCP) or Europäische Norm International Organization for Standardization (ISO EN 14155; as far as applicable) as well as all national legal and regulatory requirements. Only the study team will have access to trial specific data. Anonymisation will be achieved by a unique patient identification code. Trial data will be archived for a minimum of 10 years after study termination. We plan to publish the data in a major peer-reviewed clinical journal.

TRIALS REGISTRATION

ClinicalTrials.gov Identifier: NCT02807467 PROTOCOL VERSION: Clinical Study Protocol Version 2, 16.08.2016.

Advanced modelled iterative reconstruction for abdominal CT: qualitative and quantitative evaluation

AIM

To determine qualitative and quantitative image-quality parameters in abdominal imaging using advanced modelled iterative reconstruction (ADMIRE) with third-generation dual-source 192 section CT.

MATERIALS AND METHODS

Forty patients undergoing abdominal portal-venous CT at different tube voltage levels (90, 100, 110, and 120 kVp, n = 10 each) and 10 consecutive patients undergoing abdominal non-enhanced low-dose CT (100 kVp, 60 mAs) using a third-generation dual-source 192 section CT machine in the single-source mode were included. Images were reconstructed with filtered back projection (FBP) and ADMIRE (strength levels 1-5). Two blinded, independent readers subjectively determined image noise, artefacts, visibility of small structures, and image contrast, and measured attenuation in the liver, spleen, kidney, muscle, fat, and urinary bladder, and objective image noise.

RESULTS

Subjective noise was significantly lower and image contrast significantly higher for each increasing ADMIRE strength level and also for ADMIRE 1 compared to FBP (all, p < 0.001). No significant differences were found for artefact and visibility ratings among image sets (all, p > 0.05). Attenuation was similar across tube voltage-image datasets in all anatomical regions (all, p > 0.05). Objective noise was significantly lower for each increasing ADMIRE strength level, and for ADMIRE 1 compared to FBP (all, p < 0.001, maximal reduction 53%). Independent predictors of noise were tube voltage (p < 0.05) and current (p < 0.001), diameter (p < 0.05), and reconstruction algorithm (p<0.001); the amount of noise reduction was related only to the reconstruction algorithm (p < 0.001).

CONCLUSION

Abdominal CT using ADMIRE results in an improved image quality with lower image noise as compared with FBP, while the attenuation of various anatomical regions remains constant among reconstruction algorithms.