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Objective: Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients. This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients.Design: A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries.Interventions: None.Patients: Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period.Methods: Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method. Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia.Results: We enrolled 97 patients, mean age 64+/-15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 6.5+/-4.0. Mean IAP was 9.8+/-4.7 mmHg. The prevalence of IAH (defined as IAP 12 mmHg or more) was 50.5 and 8.2% had abdominal compartment syndrome (defined as IAP 20 mmHg or more). The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance.Conclusion: Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured. [ABSTRACT FROM AUTHOR]

Objective: To assess a novel method, adapted from already published literature, for bedside placement of nasojejunal feeding tubes using erythromycin, air insufflation of the stomach and continuous ECG guidance.Design and Setting: Prospective study in a tertiary teaching hospital.Patients and Participants: 40 consecutive patients who required enteral nutrition and mechanical ventilation for at least 48 h.Interventions: Erythromycin (200 mg) was administered intravenously 30 min prior to the insertion of the feeding tube. The post-pyloric feeding tube was then inserted into the stomach and 500 ml air insufflated. Stomach ECG was performed, and during further insertion of the tube the QRS complex was continuously monitored for a change in polarity, suggesting passage across the midline through the pylorus. At the end of the procedure aspirate was obtained from the feeding tube and checked for alkaline pH. Exact tube position was determined by abdominal radiography.Measurements and Results: In 88% of cases the feeding tubes were post-pyloric, with a median time to insertion of 15 min (range 7-75). No major complications were seen in 52 attempts. Change in QRS polarity had 94% sensitivity in predicting post-pyloric tip placement. Of the 32 alkaline pH aspirates 31 were post-pyloric.Conclusions: This procedure is safe, effective and could be performed in a short time period within the confines of the intensive care unit without endoscopic assistance. [ABSTRACT FROM AUTHOR]

Presents an algorithm that has potential to indicate the futility of continued intensive care of critically ill patients. Rising costs of intensive care; Need to recognize early those patient who will die despite treatment; Changes in a modified organ failure score; Median survival after a prediction.

Objectives: To determine whether cardiac index and intrathoracic blood volume index are "mathematically coupled" under euvolaemic conditions with increasing levels of inotropic support.Design: Prospective case series.Setting: A 14-bed general intensive care unit in a university-affiliated hospital.Patients: Twelve mechanically ventilated patients, monitored with the COLD system and receiving dobutamine as inotropic support.Intervention: After measuring cardiac index and intrathoracic blood volume index the rate of dobutamine infusion was increased until cardiac index rose by at least 20%. A further measurement of intrathoracic blood volume index was made at the new cardiac index.Measurements and Results: The mean increase in cardiac index was 31.7%, compared with a mean increase in intrathoracic blood volume index of only 2.84%.Conclusion: Under euvolaemic conditions, raising cardiac index by increasing inotropic support does not alter intrathoracic blood volume index significantly, thus demonstrating that the two measurements are not 'mathematically coupled' under these conditions. [ABSTRACT FROM AUTHOR]

Editorial. Focuses on the routine changes of central venous catheters in patients requiring prolonged intensive care. Reference to a telephone survey in the issue of the `British Medical Journal,' by Cyna et al; Risk factors associated with catheter colonization; Why there is an inaccurate perception of the size of problem; Need for the majority of British intensive care units to review their policies on inserting and changing central venous catheters.

Fluid resuscitation has long been considered a key intervention in the treatment of adults with severe falciparum malaria. Profound hypovolemia is common in these patients and has the potential to exacerbate the acidosis and acute kidney injury that are independent predictors of death. However, new microvascular imaging techniques have shown that disease severity correlates more strongly with obstruction of the microcirculation by parasitized erythrocytes--a process termed sequestration. Fluid loading has little effect on sequestration and increases the risk of complications, particularly pulmonary edema, a condition that can develop suddenly and unpredictably and that is frequently fatal in this population. Accordingly, even if a patient is clinically hypovolemic, if there is an adequate blood pressure and urine output, there may be little advantage in infusing intravenous fluid beyond a maintenance rate of 1 to 2 mL/kg per hour. The optimal agent for fluid resuscitation remains uncertain; significant anemia requires blood transfusion, but colloid solutions may be associated with harm and should be avoided. The preferred crystalloid is unclear, although the use of balanced solutions requires investigation. There are fewer data to guide the fluid management of severe vivax and knowlesi malaria, although a similar conservative strategy would appear prudent. [ABSTRACT FROM AUTHOR]