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Several systematic reviews and meta-analyses of randomized controlled trials concluded that probiotics administration in critically ill patients was safe and associated with reduced rates of ventilator-associated pneumonia and diarrhea. However, a recent large multicenter trial found probiotics administration, compared to placebo, was not efficacious and increased adverse events. An updated meta-analysis that controls for type-1 and -2 errors using trial sequential analysis, with a detailed account of adverse events associated with probiotic administration, is warranted to confirm the safety and efficacy of probiotic use in critically ill patients. RCTs that compared probiotics or synbiotics to usual care or placebo and reported clinical and diarrheal outcomes were searched in 4 electronic databases from inception to March 8, 2022 without language restriction. Four reviewers independently extracted data and assessed the study qualities using the Critical Care Nutrition (CCN) Methodological Quality Scoring System. Random-effect meta-analysis and trial sequential analysis (TSA) were used to synthesize the results. The primary outcome was ventilator-associated pneumonia (VAP). The main subgroup analysis compared the effects of higher versus lower quality studies (based on median CCN score). Seventy-five studies with 71 unique trials (n = 8551) were included. In the overall analysis, probiotics significantly reduced VAP incidence (risk ratio [RR] 0.70, 95% confidence interval [CI] 0.56–0.88; I2 = 65%; 16 studies). However, such benefits were demonstrated only in lower (RR 0.47, 95% CI 0.32, 0.69; I2 = 44%; 7 studies) but not higher quality studies (RR 0.89, 95% CI 0.73, 1.08; I2 = 43%; 9 studies), with significant test for subgroup differences (p = 0.004). Additionally, TSA showed that the VAP benefits of probiotics in the overall and subgroup analyses were type-1 errors. In higher quality trials, TSA found that future trials are unlikely to demonstrate any benefits of probiotics on infectious complications and diarrhea. Probiotics had higher adverse events than control (pooled risk difference: 0.01, 95% CI 0.01, 0.02; I2 = 0%; 22 studies). High-quality RCTs did not support a beneficial effect of probiotics on clinical or diarrheal outcomes in critically ill patients. Given the lack of benefits and the increased incidence of adverse events, probiotics should not be routinely administered to critically ill patients. CRD42022302278. [ABSTRACT FROM AUTHOR]

Risk factors for poor outcomes after critical illness are incompletely understood. While nutritional risk is associated with mortality in critically ill patients, its association with disability, cognitive, and health-related quality of life is unclear in survivors of critical illness. This study's objective was to determine whether greater nutritional risk at ICU admission is associated with greater disability, worse cognition, and worse HRQOL at 3 and 12-month follow-up. We enrolled adults (≥18 years of age) with respiratory failure or shock treated in medical and surgical intensive care units from two U.S. centers. We measured nutritional risk using the modified Nutrition Risk in Critically Ill (mNUTRIC) score (range 0–9 [ highest risk ]) at intensive care unit admission. We measured associations between mNUTRIC scores and discharge destination, disability in basic activities of daily living (ADLs) using the Katz ADL, instrumental ADLs using the Functional Activities Questionnaire (FAQ), global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), executive function using the Trail Making Test Part B (Trails B), and health-related quality of life using the SF-36, adjusting for sex, education, BMI, baseline frailty, disability, and cognition, severity of illness, days of delirium, coma, and mechanical ventilation. Of the 821 patients enrolled in the ICU, 636 patients survived to hospital discharge. We assessed outcomes in 448 of 535 survivors (84%) at 3 months and 382 of 476 survivors (80%) at 12 months. Higher mNUTRIC scores predicted greater odds of discharge to an institution (OR 2.0, 95% CI: 1.6 to 2.6; P < 0.01). Higher mNUTRIC scores were associated with a trend towards greater disability in basic activities of daily living (IRR 1.3, 95% CI 1.0 to 1.7) at 3 months that did not reach significance (p = 0.09) with no association demonstrated at 12 months. There were no associations between mNUTRIC scores and FAQ, RBANS, or Trails B scores. mNUTRIC scores were inconsistently associated with SF-36 physical and mental component scale scores. Greater nutritional risk at ICU admission is associated with disability in survivors of critical illness. Future studies should evaluate interventions in those at high nutritional risk as a means to speed recovery. [ABSTRACT FROM AUTHOR]

In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality. This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age ≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96 h in the ICU were included. US measurements were performed within 48 h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL). Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91–0.99; p = 0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F ≥4) and frailty (CFS ≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality. Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission. [ABSTRACT FROM AUTHOR]

Burn patients pose a number of clinical challenges for doctors and dietitians to achieve optimal nutrition practice. The objective of this study was to describe nutrition practices in burn center intensive care units (ICUs) compared to the most recent ESPEN and SCCM/ASPEN guidelines (hereafter referenced as "the Guidelines") and highlight the variation in practice and what is "best achievable." In 2014–15, we prospectively enrolled 283 mechanically ventilated patients who were admitted to one of 14 burn ICUs for at least 72 h. Data collected included information on the estimation of energy and protein requirements, their actual delivery as well as route and time of feeding, and administration of micronutrients. We describe site practices and data per patient-day. Adherence to the Guidelines for the use of enteral nutrition (EN) over parenteral nutrition (PN) was 90.5% of patient-days (site range 79.2%–97.0%). However, adherence to the Guidelines for the measurement of energy requirements was 6.0% of patient-days (site range 0.0%–93.3%), supplementation with glutamine took place in 22.4% of patient-days (site range 0.0%–61.8%). Provision of 80% of energy requirements within 48–72 h was achieved in 35.3% of patients (site range 0.0%–80.0%), and provision of 80% of protein needs within 48–72 h was achieved in 34.3% of patients (site range 0.0%–80.0%). Average nutritional adequacy was 64.9 ± 40.0% for energy (best site: 80.2%, worst site: 42.0%) and 65.6 ± 42.1% for protein (best site: 87.3%, worst site: 43.6%). The present findings indicate that despite high adherence to providing EN over PN, there is still a large gap between many recommendations and clinical practice, and the achievement of nutrition goals for patients in burn centers is suboptimal. [ABSTRACT FROM AUTHOR]

The quantity and quality of skeletal muscle and adipose tissue is an important prognostic factor for clinical outcomes across several illnesses. Clinically acquired computed tomography (CT) scans are commonly used for quantification of body composition, but manual analysis is laborious and costly. The primary aim of this study was to develop an automated body composition analysis framework using CT scans. CT scans of the 3rd lumbar vertebrae from critically ill, liver cirrhosis, pancreatic cancer, and clear cell renal cell carcinoma patients, as well as renal and liver donors, were manually analyzed for body composition. Ninety percent of scans were used for developing and validating a neural network for the automated segmentation of skeletal muscle and adipose tissues. Network accuracy was evaluated with the remaining 10 percent of scans using the Dice similarity coefficient (DSC), which quantifies the overlap (0 = no overlap, 1 = perfect overlap) between human and automated segmentations. Of the 893 patients, 44% were female, with a mean (±SD) age and body mass index of 52.7 (±15.8) years old and 28.0 (±6.1) kg/m2, respectively. In the testing cohort (n = 89), DSC scores indicated excellent agreement between human and network-predicted segmentations for skeletal muscle (0.983 ± 0.013), and intermuscular (0.900 ± 0.034), visceral (0.979 ± 0.019), and subcutaneous (0.986 ± 0.016) adipose tissue. Network segmentation took ~350 milliseconds/scan using modern computing hardware. Our network displayed excellent ability to analyze diverse body composition phenotypes and clinical cohorts, which will create feasible opportunities to advance our capacity to predict health outcomes in clinical populations. [ABSTRACT FROM AUTHOR]

Pharmacokinetics (PK) of pharmaceuticals and pharmaconutrients are poorly understood in critically ill patients, and dosing is often based on healthy subject data. This might be particularly problematic with enteral medications due to metabolic abnormalities and impaired gastrointestinal tract absorption common in critically ill patients. Utilizing enteral fish oil, this study was undertaken to better understand and define PK of enteral omega-3 fatty acids (eicospentaenoic acid [EPA] and docosahexaenoic acid [DHA]) in critically ill patients with severe sepsis. Healthy volunteers (n = 15) and mechanically ventilated (MV) adults with severe sepsis (n = 10) were recruited and received 9.75 g EPA and 6.75 g DHA daily in two divided enteral doses of fish oil for 7 days. Volunteers continued their normal diet without other sources of fish oil, and sepsis patients received standard enteral feeding. Blood was collected at frequent intervals during the 14-day study period. Peripheral blood mononuclear cells (PMBCs) and neutrophils were isolated and analyzed for membrane fatty acid (FA) content. Mixed linear models and t-tests were used to analyze changes in FA levels over time and FA levels at individual time points, respectively. PK parameters were obtained based on single compartment models of EPA and DHA kinetics. Healthy volunteers were 41.1 ± 10.3 years; 67% were women. In patients with severe sepsis (55.6 ± 13.4 years, 50% women), acute physiologic and chronic health evaluation (APACHE) II score was 27.2 ± 8.8 at ICU admission and median MV duration was 10.5 days. Serum EPA and DHA were significantly lower in sepsis vs. healthy subjects over time. PBMC EPA concentrations were generally not different between groups over time, while PBMC DHA was higher in sepsis patients. Neutrophil EPA and DHA concentrations were similar between groups. The half-life of EPA in serum and neutrophils was significantly shorter in sepsis patients, whereas other half-life parameters did not vary significantly between healthy volunteers and sepsis patients. While incorporation of n-3 FAs into PBMC and neutrophil membranes was relatively similar between healthy volunteers and sepsis patients receiving identical high doses of fish oil for one week, serum EPA and DHA were significantly lower in sepsis patients. These findings imply that serum concentrations and EPA and DHA may not be the dominant driver of leukocyte membrane incorporation of EPA and DHA. Furthermore, lower serum EPA and DHA concentrations suggest that either these n-3 FAs were being metabolized rapidly in sepsis patients or that absorption of enteral medications and pharmaconutrients, including fish oil, may be impaired in sepsis patients. If enteral absorption is impaired, doses of enteral medications administered to critically ill patients may be suboptimal. [ABSTRACT FROM AUTHOR]

The NUTrition Risk in the Critically Ill (NUTRIC) scoring system is a tool useful, discriminating critically-ill patients benefiting from optimal nutrition intake (>80% of prescription). Recent recommendations advocate for withholding artificial nutrition among low-NUTRIC patients, however, we hypothesized that some low-NUTRIC patients would show an association between nutrition intake and outcome. Patients were selected from the 2013–2014 International Nutrition Surveys when ICU length of stay (LICU) ≥72 h, baseline mNUTRIC score ≤4 and had at least three evaluable nutrition days (N = 2781). Proportion of prescription received during evaluable days was associated to 60-day hospital mortality by a logistic regression modelling. A priori, we expected that the association between proportion of prescription received and mortality might differ according to: LICU, BMI and prior unintentional weight loss or reduced oral intake. A total of 2781 patients fulfilled the inclusion criteria and participated in the study. Ten percent of the sample had a BMI <20 kg/m2 and 20% experienced either unintentional weight loss during the last 3 months, or reduced food intake over the last week. Sixty-day hospital mortality was 15% and median LICU reached 11.3 [6.3–21.7] days. Mean total prescription received by any means of nutritional support during the first 12 evaluable days was 57.4 ± 28.1% for energy and 53.7 ± 29.2% for protein. In the pooled, subgroup and sensitivity analyses, no significant associations were identified. Low-NUTRIC (≤4) patients demonstrate a prolonged LICU, while experiencing significant mortality and a high prevalence of malnutrition risk factors. Although improvements in mortality were not achieved with increased nutritional intake, this should not be construed as a rationale for withholding artificial nutrition among this patient group. [ABSTRACT FROM AUTHOR]

Recent studies indicate that vitamin D deficiency is associated with increased morbidity and mortality in critically ill patients. Knowledge about the functional role and clinical relevance of vitamin D for patients undergoing cardiac surgery is sparse. Therefore, we investigated the clinical significance of vitamin D levels on outcome of cardiac surgery patients. 92 patients undergoing elective cardiac surgery with cardiopulmonary arrest were included in this prospective observational pilot study. 25-hydroxyvitamin D (25OHD) and 1,25-dihydroxyvitamin D (1,25(OH) 2 D) levels were measured prior to surgery, immediately postoperatively as well as 6, 12 and 24 h after surgery. We assessed postoperative organ dysfunctions, infections and death until hospital discharge. The serum concentration of 1,25(OH) 2 D significantly decreased intraoperatively by 29.3% (p < 0.001) and was significantly lower at any postoperative time point compared to baseline values, whereas 25OHD levels did not show significant changes during the observation period. Coronary artery bypass graft (CABG) patients had significant higher baseline 1,25(OH) 2 D values than patients with valve surgery (39.7 ± 13.9 ng/l vs. 30.1 ± 14.1 ng/l, p = 0.010) or CABG + valve surgery (39.7 ± 13.9 ng/l vs. 32.6 ± 11.8 ng/l, p = 0.044). Our data showed a significant odds ratio to develop postoperative organ dysfunction (OR 0.95; p = 0.009) and PCT levels ≥5 μg/l (OR 0.94; p = 0.046) for every ng/l increment in 1,25(OH) 2 D, when performing multivariable analysis and after adjusting for preoperative illness and demographics. In addition, multivariable-adjusted statistical analyses revealed that patients stayed significantly shorter on ICU (−0.21 h; p = 0.001) and in hospital (−2.6 days; p = 0.009) for every ng/l increment in 1,25(OH) 2 D. Our data highlight important evidence about the clinical significance of 1,25(OH) 2 D levels in cardiac surgery patients. Higher levels were associated with significantly less postoperative organ dysfunctions, elevated PCT levels, death and prolonged hospital stay. 1,25(OH) 2 D levels decreased significantly intra- and postoperatively, while serum levels of 25OHD did not. clinicaltrials.gov (NCT 02488876), registered May 1, 2015. [ABSTRACT FROM AUTHOR]

Summary The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated. [ABSTRACT FROM AUTHOR]

Summary Background & aims Lean body mass (LBM), quantified using computed tomography (CT), is a significant predictor of clinical outcomes in the critically ill. While CT analysis is precise and accurate in measuring body composition, it may not be practical or readily accessible to all patients in the intensive care unit (ICU). Here, we assessed the agreement between LBM measured by CT and four previously developed equations that predict LBM using variables (i.e. age, sex, weight, height) commonly recorded in the ICU. Methods LBM was calculated in 327 critically ill adults using CT scans, taken at ICU admission, and 4 predictive equations (E1–4) that were derived from non-critically adults since there are no ICU-specific equations. Agreement was assessed using paired t -tests, Pearson's correlation coefficients and Bland–Altman plots. Results Median LBM calculated by CT was 45 kg (IQR 37–53 kg) and was significantly different (p < 0.001) from E1 (52.5 kg; IQR: 42–61 kg), E2 (55 kg; IQR 45–64 kg), E3 (55 kg; IQR 44–64 kg), and E4 (54 kg; IQR 49–61 kg). Pearson correlation coefficients suggested moderate correlation (r = 0.739, 0.756, 0.732, and 0.680, p < 0.001, respectively). Each of the equations overestimated LBM (error ranged from 7.5 to 9.9 kg), compared with LBM calculated by CT, suggesting insufficient agreement. Conclusions Our data indicates a large bias is present between the calculation of LBM by CT imaging and the predictive equations that have been compared here. This underscores the need for future research toward the development of ICU-specific equations that reliably estimate LBM in a practical and cost-effective manner. [ABSTRACT FROM AUTHOR]

Background: Conversations about goals of care in hospital are important to patients who have advanced heart failure (HF).Methods: We conducted a multicenter survey of cardiology nurses, fellows, and cardiologists at 8 Canadian teaching hospitals. The primary outcome was the importance of barriers to goals-of-care discussions in hospital (1 = extremely unimportant; 7 = extremely important). We also elicited perspectives on roles of different practitioners in having these conversations.Results: Questionnaires were returned by 770/1024 (75.2%) eligible clinicians. The most important perceived barriers were: family members' and patients' difficulty in accepting a poor prognosis (mean [SD] score 5.9 [1.1] and 5.7 [1.2], respectively), family members' and patients' lack of understanding about the limitations and harms of life-sustaining treatments (5.8 [1.1] and 5.7 [1.2], respectively), and lack of agreement among family members about goals of care (5.8 [1.2]). Interprofessional team members were viewed as having different but important roles in goals-of-care discussions.Conclusions: Cardiology clinicians perceive family and patient-related factors as the most important barriers to goals-of-care discussions in hospital. Many members of the interprofessional team were viewed as having important roles in addressing goals of care. These findings can inform the design of future interventions to improve communication about goals of care in advanced HF. [ABSTRACT FROM AUTHOR]

Context: A validated 82-item Advance Care Planning (ACP) Engagement Survey measures a broad range of behaviors. However, concise surveys are needed.Objectives: The objective of this study was to validate shorter versions of the survey.Methods: The survey included 57 process (e.g., readiness) and 25 action items (e.g., discussions). For item reduction, we systematically eliminated questions based on face validity, item nonresponse, redundancy, ceiling effects, and factor analysis. We assessed internal consistency (Cronbach's alpha) and construct validity with cross-sectional correlations and the ability of the progressively shorter survey versions to detect change one week after exposure to an ACP intervention (Pearson correlation coefficients).Results: Five hundred one participants (four Canadian and three US sites) were included in item reduction (mean age 69 years [±10], 41% nonwhite). Because of high correlations between readiness and action items, all action items were removed. Because of high correlations and ceiling effects, two process items were removed. Successive factor analysis then created 55-, 34-, 15-, nine-, and four-item versions; 664 participants (from three US ACP clinical trials) were included in validity analysis (age 65 years [±8], 72% nonwhite, 34% Spanish speaking). Cronbach's alphas were high for all versions (four items 0.84-55 items 0.97). Compared with the original survey, cross-sectional correlations were high (four items 0.85; 55 items 0.97) as were delta correlations (four items 0.68; 55 items 0.93).Conclusion: Shorter versions of the ACP Engagement Survey are valid, internally consistent, and able to detect change across a broad range of ACP behaviors for English and Spanish speakers. Shorter ACP surveys can efficiently measure broad ACP behaviors in research and clinical settings. [ABSTRACT FROM AUTHOR]

Summary Background and aims Patients with traumatic brain injury (TBI) experience considerable energy and protein deficits in the intensive care unit (ICU) and these are associated with adverse outcomes. However, nutrition delivery after ICU discharge during ward-based care, particularly from oral diet, has not been measured. This study aimed to quantify energy and protein delivery and deficits over the entire hospitalization for critically ill TBI patients. Methods Consecutively admitted adult patients with a moderate-severe TBI (Glasgow Coma Scale 3–12) over 12 months were eligible. Observational data on energy and protein delivered from all routes were collected until hospital discharge or day 90 and compared to dietician prescriptions. Oral intake was quantified using weighed food records on three pre-specified days each week. Data are mean (SD) unless indicated. Cumulative deficit is the mean absolute difference between intake and estimated requirements. Results Thirty-seven patients [45.3 (15.8) years; 87% male; median APACHE II 18 (IQR: 14–22)] were studied for 1512 days. Median duration of ICU and ward-based stay was 13.4 (IQR: 6.4–17.9) and 19.9 (9.6–32.0) days, respectively. Over the entire hospitalization patients had a cumulative deficit of 18,242 (16,642) kcal and 1315 (1028) g protein. Energy and protein intakes were less in ICU than the ward (1798 (800) vs 1980 (915) kcal/day, p = 0.015; 79 (47) vs 89 (41) g/day protein, p = 0.001). Energy deficits were almost two-fold greater in patients exclusively receiving nutrition orally than tube-fed (806 (616) vs 445 (567) kcal/day, p = 0.016) while protein deficits were similar (40 (5) vs 37 (6) g/day, p = 0.616). Primary reasons for interruptions to enteral and oral nutrition were fasting for surgery/procedures and patient-related reasons, respectively. Conclusions Patients admitted to ICU with a TBI have energy and protein deficits that persist after ICU discharge, leading to considerable shortfalls over the entire hospitalization. Patients ingesting nutrition orally are at particular risk of energy deficit. [ABSTRACT FROM AUTHOR]

Summary Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies. [ABSTRACT FROM AUTHOR]

Summary Introduction Better tools are needed to assist in the identification of critically ill patients most likely to benefit from artificial nutrition therapy. Recently, the Nutrition Risk in Critically ill (NUTRIC) score has been developed for such purpose. The objective of this study was to externally validate a modified version of the NUTRIC score in a second database. Methods We conducted a post hoc analysis of a database of a randomized control trial of intensive care unit (ICU) patients with multi-organ failure. Data for all variables of the NUTRIC score with the exception of IL-6 levels were collected. These included age, APACHE II score, SOFA score, number of co-morbidities, days from hospital admission to ICU admission. The NUTRIC score was calculated using the exact same thresholds and point system as developed previously except the IL-6 item was omitted. A logistic model including the NUTRIC score, the nutritional adequacy and their interaction was estimated to assess if the NUTRIC score modified the association between nutritional adequacy and 28-day mortality. We also examined the association of elevated NUTRIC scores and 6-month month mortality and the interaction between NUTRIC score and nutritional adequacy. Results A total of 1199 patients were analyzed. The mean total calories prescribed was 1817 cal (SD 312) with total mean protein prescribed of 98.3 g (SD 23.6). The number of patients who received PN was 9.5%. The overall 28-day mortality rate in this validation sample was 29% and the mean NUTRIC score was 5.5 (SD 1.6). Based on the logistic model, the odds of mortality at 28 days was multiplied by 1.4 (95% CI, 1.3–1.5) for every point increase on the NUTRIC score. The mean (SD) nutritional adequacy was 50.2 (29.5) with an interquartile range from 24.8 to 74.1. The test for interaction confirmed that the association between nutritional adequacy and 28-day mortality is significantly modified by the NUTRIC score (test for interaction p = 0.029). In particular, there is a strong positive association between nutritional adequacy and 28 day survival in patients with a high NUTRIC score but this association diminishes with decreasing NUTRIC score. Higher NUTRIC scores are also significantly associated with higher 6-month mortality (p < 0.0001) and again the positive association between nutritional adequacy and 6 month survival was significantly stronger (and perhaps only present) in patients with higher NUTRIC score (test for interaction p = 0.038). Conclusion The NUTRIC scoring system is externally validated and may be useful in identifying critically ill patients most likely to benefit from optimal amounts of macronutrients when considering mortality as an outcome. [ABSTRACT FROM AUTHOR]

Objectives Validated composite outcomes after complicated cardiac surgery are poorly established. Therefore, the authors evaluated a novel composite endpoint, persistent organ dysfunction (POD)+death, which is defined as any need for life-sustaining therapies or death at any time within 28 days from surgery. Design Secondary analysis extracted from a large-scale prospective randomized trial of critically ill cardiac surgery patients. Setting Multi-institutional, university hospitals. Participants Ninety-five cardiac surgery patients with complicated postoperative courses. Interventions Cardiac surgery with cardiopulmonary bypass. Measurements and Main Results At 28 days following surgery, the prevalence of POD was 15%, and 23% of patients had died (POD+death = 38%). Patients alive with POD at day 28 exhibited a significantly higher extent of organ injury and longer ICU (33 v 7 days; p<0.001) and hospital lengths of stay (49 v 21 days; p<0.001) compared to patients without POD at day 28. At 3 and 6 months, quality-of-life scores (by Short Form 36 questionnaire) showed a significantly reduced rating for most components in patients with POD at day 28 compared to those without POD. The 6-month mortality rate was 21% among patients alive with POD at day 28 compared to 5% among patients alive without POD (p = 0.05). The calculated number of patients needed per arm to detect a 25% relative risk reduction for mortality alone was 762 compared to 386 per arm for POD+ death. Conclusions POD+death at day 28 following cardiac surgery may be a valid composite endpoint and offers statistical efficiencies in terms of sample size calculations for cardiac surgical trials. [ABSTRACT FROM AUTHOR]

Summary Background & aims Adverse consequences may be experienced by critically ill patients who are underfed during their stay in the intensive care unit. The objective of this study is to determine the prevalence of iatrogenic underfeeding (receiving <80% of prescribed energy requirements) and the variation of these rates in different geographic regions of the world and in different nutritionally ‘at-risk’ patient populations. Methods This was a prospective, multi-institutional study in 201 units from 26 countries. We included 3390 mechanically ventilated patients who remained in the unit and received artificial nutrition for at least 96 h. We report time to start of enteral nutrition and % nutrition received in various geographic regions of the world and we focus on subgroups of ‘high risk’ patients (those with >7 days of mechanical ventilation, body mass index of <25 or ≥35, and those with a Nutrition Risk In the Critically ill (NUTRIC) score of ≥5). We report rates of novel enteral nutrition delivery techniques and supplemental parenteral nutrition in these high risk patients. Results On average, enteral feedings were started 38.8 h (standard deviation: 39.6) after admission, patients received 61.2% of calories and 57.6% of protein prescribed, and 74.0% of patients failed to meet the quality metric of receiving at least 80% of energy targets. There were significant differences in nutrition outcomes across different geographic regions. There were no clinically important differences in nutrition outcomes or rates of iatrogenic underfeeding in patients in different BMI groups nor by NUTRIC score. Of all at-risk patients, 14% were ever prescribed volume-based feeds, and 15% of patients ever received supplemental parenteral nutrition. Conclusions Worldwide, the majority of critically ill patients, including high nutritional risk patients, fail to receive adequate nutritional intake. There is low uptake of strategies designed to optimize nutrition delivery in these patients. [ABSTRACT FROM AUTHOR]

Background: The impact of protein intake on outcomes in pediatric critical illness is unclear. Objective: We examined the association between protein intake and 60-d mortality in mechanically ventilated children. Design: In a prospective, multicenter, cohort study that included 59 pediatric intensive care units (PICUs) from 15 countries, we enrolled consecutive children (age: 1 mo to 18 y) who were mechanically ventilated for ≥48 h. We recorded the daily and cumulative mean adequacies of energy and protein delivery as a percentage of the prescribed daily goal during the PICU stay ≤10 d. We examined the association of the adequacy of protein delivery with 60-d mortality and determined variables that predicted protein intake adequacy. Results: We enrolled 1245 subjects (44% female) with a median age of 1.7 y (IQR: 0.4, 7.0 y). A total of 985 subjects received enteral nutrition, 354 (36%) of whom received enteral nutrition via the post-pyloric route. Mean ± SD prescribed energy and protein goals were 69 ± 28 kcal/kg per day and 1.9 ± 0.7 g/kg per day, respectively. The mean delivery of enteral energy and protein was 36 ± 35% and 37 ± 38%, respectively, of the prescribed goal. The adequacy of enteral protein intake was significantly associated with 60-d mortality (P < 0.001) after adjustment for disease severity, site, PICU days, and energy intake. In relation to mean enteral protein intake <20%, intake ≥60% of the prescribed goal was associated with an OR of 0.14 (95% CI: 0.04, 0.52; P = 0.003) for 60-d mortality. Early initiation, postpyloric route, shorter interruptions, larger PICU size, and a dedicated dietitian in the PICU were associated with higher enteral protein delivery. Conclusions: Delivery of >60% of the prescribed protein intake is associated with lower odds of mortality in mechanically ventilated children. Optimal prescription and modifiable practices at the bedside might enhance enteral protein delivery in the PICU with a potential for improved outcomes. This trial was registered at clinicaltrials.gov as NCT02354521. [ABSTRACT FROM AUTHOR]

Abstract: Context: The recently developed Canadian Health Care Evaluation Project (CANHELP) questionnaire, which can be used to assess both patient and family satisfaction with end-of-life care, takes 40–60 minutes to complete. The length of the interview may limit its uptake and clinical utility; a shorter version would make its use more feasible. Objectives: The purpose of this study was to develop and validate a shorter version of the CANHELP questionnaire. Methods: Data were collected using a cross-sectional survey of patients with advanced medical diseases and their family members. Participants completed the long version of CANHELP, a global rating of satisfaction with care (GRS), the FAMCARE scale (family members only), and a quality-of-life (QOL) questionnaire. We reduced the items on the long version based on their relationship to the GRS, the frequency of missing data, the distribution of responses, the redundancy of the items, and focus groups with frontline users. With the remaining items, we assessed internal consistency using Cronbach's alpha, and evaluated construct validity by describing the correlation of the new CANHELP Lite with the full version of CANHELP, GRS, FAMCARE, and the QOL questionnaire scores. Results: A total of 363 patients and 193 family members participated in this study. The patient version was reduced from 37 items to 20 items and the caregiver version was reduced from 38 items to 21 items. Cronbach's alphas ranged from 0.68 to 0.93 for all domains of both the patient and caregiver questionnaires. We observed a high degree of correlation between CANHELP Lite domains and overall scores and the same domains and overall scores for the full version of CANHELP. In addition, we observed moderate to strong correlation between the CANHELP Lite overall satisfaction scores and the GRS questions. There was moderate correlation between the overall family member CANHELP Lite score and overall FAMCARE score (r = 0.45) and this was similar to the correlation between the full version of CANHELP and FAMCARE scores (r = 0.41). CANHELP Lite correlated more strongly with the QOL subscale on health care than the other QOL subscales. Conclusion: The CANHELP Lite questionnaire is a valid and internally consistent instrument to measure satisfaction with end-of-life care. [Copyright &y& Elsevier]

Purpose: The aims of this study were to describe the barriers to enterally feeding critically ill patients from a nursing perspective and to examine whether these barriers differ across centers. Materials and Methods: Across-sectional survey was conducted in 5 hospitals in North America. A 45-item questionnaire was administered to critical care nurses to evaluate the barriers to enterally feeding patients. Results: A total of 138 of 340 critical care nurses completed the questionnaire (response rate of 41%). The 5 most important barriers to nurses were as follows: (1) other aspects of patient care taking priority over nutrition, (2) not enough feeding pumps available, (3) enteral formula not available on the unit, (4) difficulties in obtaining small bowel access in patients not tolerating enteral nutrition, and (5) no or not enough dietitian coverage during weekends and holidays. For 18 (81%) of 22 potential barriers, the rated magnitude of importance was similar across the 5 intensive care units. Conclusion: Nurses in our multicenter survey identified important barriers to providing adequate enteral nutrition to their critically ill patients. The importance of these barriers does not appear to differ significantly across different clinical settings. Future research is required to evaluate if tailoring interventions to overcome these identified barriers is an effective strategy of improving nutrition practice. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. Materials and Methods: In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Results: Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. Conclusion: Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. [Copyright &y& Elsevier]

Summary: Background and aims: The objective of this study was to evaluate the relationship between increasing success with enteral nutrition (EN) and acquired infection in the Intensive Care Unit (ICU). Methods: We conducted a prospective, multicenter, observational study in 3 Medical/Surgical ICUs. We included patients mechanically ventilated in ICU more than 72h and who received enteral nutrition only. Charts were reviewed to determine success with EN delivery and clinical outcomes. Suspected infections were adjudicated by 2 or more clinicians to determine the presence or absence of infection (rated as either probable or possible infection). Results: Of the 207 patients included in this analysis, the average age was 62.0 years; APACHE II score was 23.3; BMI: 28.5; and 73% were medical. Overall, patients received 48.9% (range 0–120%) of their energy and 45.1% (range 0–120%) of their protein requirements from EN. Overall, 25.1% developed an infection after 72h from admission, 21.7% developed an infection after 96h from admission, and the 28-day mortality was 29.0%. In a regression model, greater amounts of energy and protein were consistently associated with a reduction in infection. However, estimates only achieved levels near statistical significance for risk of at least 1 probable infection after >96h (Odds Ratio [0R]: 0.32, 95% Confidence Interval [CI]: 0.10–1.02, p =0.054 and OR: 0.40, 95% CI: 0.18–0.89, p =0.024 per 1000kcal/day energy and 30grams/day protein, respectively). In all cases, the OR was lower when considering infections that developed after 96h compared to infections that developed after 72h and when considering ‘Probable’ infections compared to all infections which included ‘Possible’ infections. Conclusions: Successful EN may be associated with a reduction in infectious complications, particularly after 96h of ICU admission. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs). Materials and Methods: We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN ÷ energy prescribed by the dietitian × 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy. Results: The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs. Conclusions: Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to determine the safety of targeted antibiotic therapy (TT) in ventilator-associated pneumonia (VAP). Materials and Methods: This was a secondary analysis from a multicenter trial of 740 patients with suspected VAP randomized to bronchoscopy or endotracheal aspirate cultures; all received empirical broad-spectrum antibiotics. Patients were grouped by whether they received TT, defined as tailoring or discontinuing antibiotics in response to enrolment culture results. Results: For patients with a positive culture (n = 412), baseline demographics, clinical progression of infection and multiple organ dysfunction scores (MODS), and mortality were similar for those on TT (n = 320) or those who did not receive TT (NoTT) (n = 92). The TT group had more days alive and off broad-spectrum antibiotics (14.5 vs 13.2, P = .04). In patients with a negative culture (n = 327), those on TT (n = 230) had similar baseline demographics, less frequent final adjudicated diagnosis of VAP (63.0% vs 76.3%, P = .02), and less severe clinical progression of infection and MODS compared with NoTT (n = 97). The TT group had more days alive and off broad-spectrum antibiotics (15.9 vs 13.1, P < .001), lower δ MODS (2.0 vs 3.0, P = .01), fewer mechanical ventilation days (9.8 vs 14.7, P = .03), and similar mortality compared to NoTT. Conclusions: Targeted therapy is associated with less antibiotic use and no evidence of harm in the management of patients with VAP. [Copyright &y& Elsevier]

Abstract: Purpose: Gram stains of endotracheal aspirates (EA) and bronchoalveolar lavages (BAL) may guide empiric antibiotic therapy in critically ill patients with suspected ventilator-associated pneumonia (VAP). Previous studies differ regarding the ability of the Gram stain to predict final culture results. The aim of the present study was to evaluate the relationship between EA or BAL Gram stains and final culture results in intensive care unit patients with a suspected VAP. Material and Methods: We retrospectively analyzed data from the Canadian multicenter VAP study to correlate EA or BAL Gram stain and final culture results. We categorized Gram stains as Gram positive (GP) and Gram negative (GN) if any GP or GN organisms respectively were seen on staining. Cultures were considered “positive” if they yielded pathogenic organisms on final results. Results: Seven hundred forty patients were enrolled in the study; 35 did not have a Gram stain done leaving 350 BALs and 355 EAs from 705 patients. Pooling BAL and EA results, we found the overall agreement between Gram stain class and pathogenic bacteria culture results to be poor (κ = 0.36; 95% CI, 0.31-0.40). Among specimens with Gram stains showing no organisms, 99 (30%) of 331 grew pathogenic organisms. Among specimens with Gram stains showing no GN organisms, 113 (25%) of 452 grew pathogenic GN organisms. Among specimens with Gram stains showing no GP organisms, 45 (11%) of 428 grew pathogenic GP organisms. Conclusions: Gram stains performed for clinically suspected VAP poorly predict the final culture result and thus have a limited role in guiding initial empiric antibiotic therapy in such patients. [Copyright &y& Elsevier]

Abstract: Introduction: In the absence of a reference standard, a probabilistic approach to the diagnosis of ventilator-associated pneumonia (VAP) has been proposed; and clinician judgment augmented by microbiological tests is used to guide therapy for patients having a clinical suspicion of VAP (CSVAP). However, the correlation of both clinician judgment at the time of CSVAP and the probability of VAP with clinical outcomes is unknown. In a cohort of patients with CSVAP, we sought to determine the correlation of clinician judgment and the probability of VAP with clinical outcomes. In addition, we studied the impact of the clinical and microbiological components of CSVAP on the processes of care and outcomes. Methods: We performed a retrospective analysis of data from a multicenter, randomized trial in 740 patients with CSVAP. Prospective clinician judgment of VAP probability at the time of CSVAP and retrospective adjudication of VAP were compared with clinical outcomes. The following determinants of CSVAP on outcomes were studied: time of CSVAP, index culture results, and the presence of bacteremia. Results: Neither clinician index of suspicion for VAP nor retrospective adjudication of VAP correlated with clinical outcomes. For CSVAP, occurrence >7 days after start of mechanical ventilation and negative index cultures were associated with worse outcomes. Bacteremia was associated with the development of increased organ dysfunction. Conclusion: In patients with CSVAP, clinician judgment as to the probability of VAP does not correlate with processes of care and outcomes; and its use to group patients into those with and without VAP is of limited clinical utility. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria (“high risk” pathogens) from respiratory secretions. Materials and Methods: Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. Results: At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay ≥48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). Conclusions: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes. [Copyright &y& Elsevier]

Abstract: Purpose: Clinical uncertainty exists regarding the significance of colonization confined to respiratory tract secretions with Candida sp in critically ill patients. Our objectives were to describe such colonization, its associated risk factors, and to examine the clinical outcomes in patients with a clinical suspicion of ventilator-associated pneumonia with isolated Candida colonization compared to those without. Materials and Methods: In a retrospective analysis of the Canadian ventilator-associated pneumonia study, patients were divided into 2 groups according to the isolated presence or absence of Candida in the respiratory tract enrollment culture. We compared length of mechanical ventilation, intensive care unit and hospital stay, and mortality outcomes between groups. We used multiple logistic regression analysis to determine factors independently associated with Candida colonization and hospital mortality. Results: Of the 639 eligible patients, 114 (17.8%) were colonized with Candida in the enrollment culture. A multivariate analysis identified female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.02-2.65), number of comorbidities (OR, 1.35; 95% CI, 1.08-1.71), worsening or persistent infiltrate at randomization (OR, 1.92; 95% CI, 1.09-1.38), antibiotics started within 3 days of randomization (OR, 3.16; 95% CI, 1.71-5.83), and on antibiotics at randomization but all started more than 3 days before randomization (OR, 3.04; 95% CI, 1.68-5.50) as variables associated with Candida respiratory tract colonization. A significant increase in median hospital stay (59.9 vs 38.6 days, P = .006) and hospital mortality (34.2% vs 21.0%, P = .003) was observed in patients with Candida colonization. In a multivariate model, Candida colonization of the respiratory tract was independently associated with hospital mortality (OR, 2.47; 95% CI, 1.39-4.37). Conclusion: Respiratory tract Candida colonization is associated with worse clinical outcomes and is independently associated with increased hospital mortality. However, it is unclear whether Candida colonization is causally related to poor outcomes or whether it is a marker for increased morbidity and mortality. [Copyright &y& Elsevier]

Abstract: Introduction: Ventilator-associated pneumonia (VAP) is a cause of morbidity and mortality in critically ill patients. It is associated with increased health care costs and duration of mechanical ventilation. Using published data and information from public health care providers, we sought to determine the impact of VAP on the Canadian health care system. Methods: Ventilator-associated pneumonia incidence, attributable mortality, and intensive care unit (ICU) utilization/resource data were obtained through Canadian published and institutional data. Ontario case cost methodology was used for the cost of a critical care bed which is CAN$2396 per day, excluding treatment costs. Antibiotic acquisition costs for Ontario were used. Physician reimbursement rates were obtained from the provincial ministries of health. Ventilator-associated pneumonia data, ICU resource data, and costs were combined to determine the impact of VAP. Results: For the Canadian health care system; ICU utilization is 217 episodes per 100000 population and 1150 days of mechanical ventilation per 100000. The incidence of VAP is 10.6 cases per 1000 ventilator days (95% CI, 5.1-16.1). Ventilator-associated pneumonia increases ICU length of stay 4.3 days (95% CI, 1.5-7.0 days) per episode. The attributable mortality of VAP is 5.8% (95% CI, −2.4 to 14). The number of cases of VAP is estimated to be approximately 4000 cases per year (95% CI, 1900-6100). This results in 230 deaths per year with the lower and upper confidence intervals ranging from 0 to 580. Ventilator-associated pneumonia accounts for approximately 17000 ICU days per year or around 2% of all ICU days in Canada. The cost to the health care system is CAN$46 million (possible range, $10 million to 82 million) per year. Conclusion: The impact of VAP on the Canadian health care system is considerable. Eradication of this preventable nosocomial infection would save lives and conserve scarce health care resources. [Copyright &y& Elsevier]

Abstract: Background: Venous thromboembolism (VTE) can be a life-threatening complication of critical illness. Venous thromboembolism rates observed depend on the population studied, the screening modality used, and thromboprophylaxis prescribed. Few studies report on the rates of clinically diagnosed VTE in critically ill patients. The purpose of this study was to characterize the incidence of clinically diagnosed VTE, prophylactic strategies used, and diagnostic studies ordered in a critically ill population at a tertiary community intensive care unit (ICU), both during and after their ICU stay. Methods: We did a retrospective chart review of 600 consecutive critically ill patients admitted to a tertiary community ICU. Results: Fifty (8.3%) patients developed VTE over the course of their ICU and hospital stay (18 [3.0%] patients during their ICU stay and 32 [5.7% of 561 ICU survivors] patients after ICU discharge). By ICU admission diagnosis, most events occurred in neurosurgical patients, although this group comprised only 24.8% of the population. Across all subgroups, most VTE events occurred after ICU discharge. Intensive care unit patients received thromboprophylaxis 87.6% (95% confidence interval, 81.5-93.7) of the time spent in ICU. However, thromboprophylaxis was administered significantly less often after transfer to the ward compared with within the ICU (from 87.6% to 59.8%, P < .001). Conclusion: The rates of clinically diagnosed VTE rates in critically ill patients are substantial. Venous thromboembolism occurs before, during, and after ICU discharge. Continued vigilance and thromboprophylaxis are warranted across the continuum of critical illness. [Copyright &y& Elsevier]

Abstract: Purpose: The frequency of clinically diagnosed venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) in medical-surgical critically ill patients is unclear. The objectives of this study were to estimate the prevalence and incidence of radiologically confirmed DVT and PE in medical-surgical intensive care unit (ICU) patients and to determine the impact of prophylaxis on the frequency of these events. Materials and Methods: In a retrospective observational cohort study in 12 adult ICUs, we identified prevalent cases (diagnosed in the 24 hours preceding ICU admission up to 48 hours post-ICU admission) and incident cases (diagnosed 48 hours or more after ICU admission and up to 8 weeks after ICU discharge) of upper or lower limb DVT or PE. Deep venous thrombosis was diagnosed by compression ultrasound or venogram. Each DVT was classified as clinically suspected or not clinically suspected in that the latter was diagnosed by scheduled screening ultrasonography. Pulmonary embolism was diagnosed by ventilation-perfusion lung scan, computed tomography pulmonary angiography, echocardiography, electrocardiography, or autopsy. Results: Among 12338 patients, 252 (2.0%) patients had radiologically confirmed DVT or PE and another 47 (0.4%) had possible DVT or PE. Prevalent DVTs were diagnosed in 0.4% (95% confidence interval [CI], 0.3%-0.5%) of patients and prevalent PEs were diagnosed in 0.4% (95% CI, 0.3%-0.6%). Incident DVTs were diagnosed in 1.0% (95% CI, 0.8%-1.2%) of patients, and incident PEs were diagnosed in 0.5% (95% CI, 0.4%-0.6%). Of patients with incident VTE, 65.8% of cases occurred despite receipt of thromboprophylaxis for at least 80% of their days in ICU. The median (interquartile range) ICU length of stay was similar for patients with DVT (7 [3-17]) and PE (5 [2-8]). For all patients with VTE, ICU mortality was 16.7% (95% CI, 12.0%-21.3%) and hospital mortality was 28.5% (95% CI, 22.8%-34.1%). Conclusions: Venous thromboembolism appears to be an apparently infrequent, but likely underdiagnosed problem, occurring among patients receiving prophylaxis. Findings suggest the need for increased suspicion among clinicians, renewed efforts at thromboprophylaxis, and evaluation of superior prevention strategies. [Copyright &y& Elsevier]

Abstract: Purpose: To describe perspectives of nurses (RNs) and respiratory therapists (RTs) related to end-of-life care for critically ill patients. Methods: For patients who had life support withdrawn in 4 Canadian university-affiliated ICUs, RNs and RTs reported their comfort level with decision making and process for 14 aspects of end-of-life care. Results: Ninety-eight patients had life support withdrawn. Responses were received from 96 (98.0%) bedside RNs and 73 (74.5%) RTs. Most RNs (85/94, 90.4%) and RTs (50/73, 68.5%) were very comfortable with decisions to withhold cardiopulmonary resuscitation or to withdraw life support (83/94, 88.3% of RNs and 56/73, 76.7% of RTs). Most RNs (range 71.3%-80.65%) and RTs (60.0%-70.8%) were very comfortable with ventilation/oxygen withdrawal and sedation. Among paired responses for 72 (73.5%) of 98 patients, RTs rated less favorably than RNs (P < .05): the quality of the physician explanation of the life support withdrawal process, the availability of the physician, the peacefulness of the dying process, and the amount of privacy for families. Suggested improvements included earlier and more inclusive discussions, clearer plans, and better preparation of families and the ICU team for patients'' deaths. Conclusions: Most RNs and RTs were comfortable with decision making and the process of life support withdrawal, but they suggested several ways to improve end-of-life care. [Copyright &y& Elsevier]

Discusses the efficacy of randomized clinical trials (RCT) as one of the best tools for therapeutic interventions. Application of surrogate outcomes in the context of clinical trials; Methodological quality of RCT; Discussion on the problem of limited generalizability of single-site studies.

Context Standardized outcomes that define successful advance care planning (ACP) are lacking. Objective The objective of this study was to create an Organizing Framework of ACP outcome constructs and rate the importance of these outcomes. Methods This study convened a Delphi panel consisting of 52 multidisciplinary, international ACP experts including clinicians, researchers, and policy leaders from four countries. We conducted literature reviews and solicited attendee input from five international ACP conferences to identify initial ACP outcome constructs. In five Delphi rounds, we asked panelists to rate patient-centered outcomes on a seven-point “not-at-all” to “extremely important” scale. We calculated means and analyzed panelists' input to finalize an Organizing Framework and outcome rankings. Results Organizing Framework outcome domains included process (e.g., attitudes), actions (e.g., discussions), quality of care (e.g., satisfaction), and health care (e.g., utilization). The top five outcomes included 1) care consistent with goals, mean 6.71 (±SD 0.04); 2) surrogate designation, 6.55 (0.45); 3) surrogate documentation, 6.50 (0.11); 4) discussions with surrogates, 6.40 (0.19); and 5) documents and recorded wishes are accessible when needed 6.27 (0.11). Advance directive documentation was ranked 10th, 6.01 (0.21). Panelists raised caution about whether “care consistent with goals” can be reliably measured. Conclusion A large, multidisciplinary Delphi panel developed an Organizing Framework and rated the importance of ACP outcome constructs. Top rated outcomes should be used to evaluate the success of ACP initiatives. More research is needed to create reliable and valid measurement tools for the highest rated outcomes, particularly “care consistent with goals.” [ABSTRACT FROM AUTHOR]