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Background Bioelectrical impedance analysis (BIA) is a validated method to assess body composition in persons with fluid homeostasis and reliable body weight. This is not the case during critical illness. The raw BIA markers resistance, reactance, phase angle, and vector length are body weight independent. Phase angle reflects cellular health and has prognostic significance. We aimed to assess the course of phase angle and vector length during intensive care unit (ICU) admission, and determine the relation between their changes ([DELTA]) and changes in body hydration. Methods A prospective, dual-center observational study of adult ICU patients was conducted. Univariate and multivariable regression analyses were performed, including reactance as a marker of cellular mass and integrity and total body water according to the Biasioli equation (TBW.sub.Biasioli) and fluid balance as body weight independent markers of hydration. Results One hundred and fifty-six ICU patients (mean [plus or minus] SD age 62.5 [plus or minus] 14.5 years, 67% male) were included. Between days 1 and 3, there was a significant decrease in reactance/m (-2.6 [plus or minus] 6.0 [ohm sign]), phase angle (-0.4 [plus or minus] 1.1°), and vector length (-12.2 [plus or minus] 44.3 [ohm sign]/m). Markers of hydration significantly increased. [DELTA]phase angle and [DELTA]vector length were both positively related to [DELTA]reactance/m (r.sup.2 = 0.55, p < 0.01; r.sup.2 = 0.38, p < 0.01). Adding [DELTA]TBW.sub.Biasioli as explaining factor strongly improved the association between [DELTA]phase angle and [DELTA]reactance/m (r.sup.2 = 0.73, p < 0.01), and [DELTA]vector length and [DELTA]reactance/m (r.sup.2 = 0.77, p < 0.01). Conclusions Our results show that during critical illness, changes in phase angle and vector length partially reflect changes in hydration., Author(s): Nadine Denneman [sup.1], Lara Hessels [sup.2], Bo Broens [sup.1], Jolijn Gjaltema [sup.1], Sandra N. Stapel [sup.1], Julius Stohlmann [sup.1], Maarten W. Nijsten [sup.2], Heleen M. Oudemans-van Straaten [sup.1] Author [...]

Purpose Patients with reduced muscle mass have a worse outcome, but muscle mass is difficult to quantify in the ICU. Urinary creatinine excretion (UCE) reflects muscle mass, but has not been studied in critically ill patients. We evaluated the relation of baseline UCE with short-term and long-term mortality in patients admitted to our ICU. Methods Patients who stayed [greater than or equal to] 24 h in the ICU with UCE measured within 3 days of admission were included. We excluded patients who developed acute kidney injury stage 3 during the first week of ICU stay. As muscle mass is considerably higher in men than women, we used sex-stratified UCE quintiles. We assessed the relation of UCE with both in-hospital mortality and long-term mortality. Results From 37,283 patients, 6151 patients with 11,198 UCE measurements were included. Mean UCE was 54% higher in males compared to females. In-hospital mortality was 17%, while at 5-year follow-up, 1299 (25%) patients had died. After adjustment for age, sex, estimated glomerular filtration rate, body mass index, reason for admission and disease severity, patients in the lowest UCE quintile had an increased in-hospital mortality compared to the patients in the highest UCE quintile (OR 2.56, 95% CI 1.96-3.34). For long-term mortality, the highest risk was also observed for patients in the lowest UCE quintile (HR 2.32, 95% CI 1.89-2.85), independent of confounders. Conclusions In ICU patients without severe renal dysfunction, low urinary creatinine excretion is associated with short-term and long-term mortality, independent of age, sex, renal function and disease characteristics, underscoring the role of muscle mass as risk factor for mortality and UCE as relevant biomarker., Author(s): Lara Hessels [sup.1], Niels Koopmans [sup.2], Antonio W. Gomes Neto [sup.3], Meint Volbeda [sup.1], Jacqueline Koeze [sup.1], Annemieke Oude Lansink-Hartgring [sup.1], Stephan J. Bakker [sup.3], Heleen M. Oudemans-van Straaten [...]

Background In patients treated with continuous renal replacement therapy (CRRT), early net ultrafiltration (NUF) rates may be associated with differential outcomes. We tested whether higher early NUF rates are associated with increased mortality in CRRT patients. Methods We performed a retrospective, observational study of all patients treated with CRRT within 14 days of intensive care unit admission. We defined the early (first 48 h) NUF rate as the volume of fluid removed per hour adjusted for patient body weight and analysed as a categorical variable (>1.75, 1.01–1.75 and <1.01 mL/kg/h). The primary outcome was 28-day mortality. To deal with competing risk, we also compared different time epochs. Results We studied 347 patients {median age 64 [interquartile range (IQR) 53–71] years and Acute Physiology and Chronic Health Evaluation III score 73 [IQR 54–90]}. Compared with NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h were associated with greater mortality rates in each epoch: Days 0–5, adjusted hazard ratio (aHR) 1.27 [95% confidence interval (CI) 1.21–1.33]; Days 6–10, aHR 1.62 (95% CI 1.55–1.68); Days 11–15, aHR 1.87 (95% CI 1.79–1.94); Days 16–26, aHR 1.92 (95% CI 1.84–2.01) and Days 27–28, aHR 4.18 (95% CI 3.98–4.40). For every 0.5 mL/kg/h NUF rate increase, mortality similarly increased during these epochs. Conclusion Compared with early NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h are associated with increased mortality. These observations provide the rationale for clinical trials to confirm or refute these findings. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about early (first 48 h) hourly and cumulative fluid balance (FB) during continuous renal replacement therapy (CRRT). Objectives: To study the characteristics and outcome associations of early hourly and cumulative FB. Methods: We studied FB in CRRT patients (2016–2018). Results: Among 350 patients, mean hourly FB became negative after 20 CRRT hours, but within 6 CRRT hours in patients with baseline fluid overload. A negative early FB was never achieved in patients receiving vasopressor therapy (p < 0.001). Mortality was 31%. The percentage of hourly negative FB was independently associated with decreased ICU mortality. A time-weighted hourly FB between 18.5 and –33 mL/h was also significantly and independently associated with decreased mortality. Conclusions: In CRRT patients, an early FB conservative approach is possible, modulated by patient characteristics, and associated with a low mortality. Moreover, avoidance of an early positive FB is associated with decreased mortality. [ABSTRACT FROM AUTHOR]

The conventional model on the distribution of electrolyte infusions states that water will distribute proportionally over both the intracellular (ICV) and extracellular (ECV) volumes, while potassium homes to the ICV and sodium to the ECV. Therefore, total body potassium is the most accurate measure of ICV and thus potassium balances can be used to quantify changes in ICV. In cardiothoracic patients admitted to the ICU we performed complementary balance studies to measure changes in ICV and ECV. In 39 patients, fluid, sodium, potassium, and electrolyte-free water (EFW) balances were determined to detect changes in ICV and ECV. Cumulatively over 4 days, these patients received a mean ± SE infusion of 14.0 ± 0.6 L containing 1465 ± 79 mmol sodium, 196 ± 11 mmol potassium and 2.1 ± 0.1 L EFW. This resulted in strongly positive fluid (4.0 ± 0.6 L) and sodium (814 ± 75 mmol) balances but in negative potassium (-101 ± 14 mmol) and EFW (-1.1 ± 0.2 L) balances. We subsequently compared potassium balances (528 patients) and fluid balances (117 patients) between patients who were assigned to either a 4.0 or 4.5 mmol/L blood potassium target. Although fluid balances were similar in both groups, the additionally administered potassium (76 ± 23 mmol) in the higher target group was fully excreted by the kidneys (70 ± 23 mmol). These findings indicate that even in the context of rapid and profound volume expansion neither water nor potassium moves into the ICV. [ABSTRACT FROM AUTHOR]

Background: Acute pulmonary oedema is a life-threatening syndrome diagnosed based on radiological and clinical findings. However, to our knowledge, no studies have investigated this syndrome in critically ill patients. Objective: To describe the prevalence of radiologically and clinically diagnosed pulmonary oedema (RCDPO) in critically ill patients, characteristics of diagnosed patients, and treatments and outcomes in this patient population. Methods: We conducted a retrospective study using natural language processing to identify all radiological reports of pulmonary oedema among patients who had been admitted to single tertiary intensive care unit (ICU) over a 1-year period (January 2015 to January 2016). We reviewed clinical data, discharge diagnosis, treatment and outcomes for such patients, and used multivariable logistic regression analysis to identify the association of RCDPO with various outcomes. Results: Out of 2001 ICU patients, we identified 238 patients (11.9%) with RCDPO. Patients with RCDPO were more acutely ill, had more chronic liver disease and had more chronic renal failure than critically ill patients who did not have RCDPO. They were typically admitted with acute cardiovascular disease; were more likely to receive invasive mechanical ventilation and continuous renal replacement therapy; had longer duration of ICU and hospital stay; were more likely to die in hospital; and, if discharged alive, were more likely to be admitted to a chronic care facility. In total, 46 RCDPO patients (19.3%) died in hospital. On multivariable analysis, only age and continuous renal replacement therapy were independently associated with mortality. In contrast, invasive mechanical ventilation was associated with a 2.5 times greater odds of radiological resolution. Conclusion: RCDPO affected about one in eight ICU patients. Such patients were sicker and had more comorbidities. The presence of RCDPO was independently associated with higher risk of death. Invasive mechanical ventilation was the only intervention independently associated with greater odds of radiological resolution., Competing Interests: No relevant disclosures., (© 2021 College of Intensive Care Medicine of Australia and New Zealand.)

Objective: To test the effectiveness of chewing gum in the prophylaxis of postoperative nausea and vomiting (PONV) in patients admitted to the intensive care unit (ICU) after surgery. Design: Prospective, open label, pilot randomised controlled trial. Setting: Two metropolitan ICUs. Participants: Ninety postoperative adult patients admitted to the ICU. Intervention: Patients administered chewing gum, who chewed for at least 15 minutes every 4 hours, were compared with a control group, who were administered a 20 mL sip of water orally every 4 hours. Main outcome measures: The primary outcome was the number of patient-reported episodes of nausea in the first 24 hours after the operation. Secondary outcomes included vomiting or dry retching episodes, and duration and severity of nausea. Results: Forty-six patients were randomly allocated to chewing gum and 44 patients to water. There was no difference between groups in the number of patients with nausea (10 [22%] chewing gum v 12 [27%] control patients; P = 0.72), nausea episodes (22 episodes; [median, 0; IQR, 0-0] v 21 episodes [median, 0; IQR, 0-1] per patient in each group respectively), vomiting/retching (2 [4%] chewing gum v 6 [14%] control patients; P = 0.24), or duration/severity of nausea. Conclusion: Regular postoperative administration of chewing gum in a surgical ICU patient cohort did not reduce nausea, vomiting or retching. The prevalence of PONV is less than previously reported. Our findings can inform future studies of PONV prophylaxis in post-surgical ICU patients. Trial registration: Australian New Zealand Clinical Trial Registry No. ACTRN12617001185358., Competing Interests: None declared., (© 2020 College of Intensive Care Medicine of Australia and New Zealand.)

BACKGROUND Donor hypernatremia has been associated with reduced graft and recipient survival after heart, liver, kidney, and pancreas transplantation. However, it is unknown what effect donor hypernatremia has on graft and recipient outcomes after lung transplantation. The aim of this study was to investigate the relation of donor hypernatremia with the duration of postoperative mechanical ventilation, the incidence of severe primary graft dysfunction, and survival following lung transplantation. MATERIAL AND METHODS We analyzed all consecutive lung transplantations performed in adult patients at our center between 1995 and 2016. During the study period, donor hypernatremia was not considered a reason to reject lungs for transplantation. Donors were classified into 3 groups: normonatremia (sodium <145 mmol/L), moderate hypernatremia (sodium 145-154 mmol/L), or severe hypernatremia (sodium ≥155 mmol/L). Short-term outcome was defined by the duration of mechanical ventilation and incidence of primary graft dysfunction; long-term outcome was defined by 10-year mortality. RESULTS Donor hypernatremia was recorded in 275 (58%) of the 474 donors. There were no differences in baseline characteristics between the 3 study groups. The duration of mechanical ventilation was similar for all groups (8±25, 7±17, and 9±15 days respectively, P=0.204). Severe primary graft dysfunction was not different between the 3 groups (29%, 26%, 28%, P=0.724). Donor hypernatremia was not associated with (graft) survival, or after correction for potential confounders. CONCLUSIONS Donor hypernatremia was not associated with a worse outcome in lung transplant recipients. Thus, in contrast to solid organ transplantation, donor hypernatremia is not a contraindication for lung transplantation.