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OBJECTIVE To identify those congenital fetal anomalies, previously identified by ultrasound scanning, in which fast-scan magnetic resonance imaging (F-SMRI) would give additional information for the perinatal management of the infants. DESIGN Observational clinical study. SETTING Hospital Department of Obstetrics and Gynaecology/Resonance Research Centre. SUBJECTS Seven women carrying eight fetuses in whom congenital abnormalities had been identified using ultrasound scans. The duration of the pregnancies was 28 to 39 weeks gestation. INTERVENTIONS Fast-scan magnetic resonance imaging at between 28 and 39 weeks gestation. MAIN OUTCOME MEASURES Identification of fetal abnormalities. RESULTS AND CONCLUSIONS F-SMRI was of limited value in the diagnosis of further assessment of fetuses with abnormalities of accumulation of tissue fluid. Renal anomalies were poorly identified unless associated with cystic formation of the kidney. Further study is required in the imaging of fetal central nervous system anomalies. Until echoplanar imaging is more widely available, MRI does not contribute to the diagnosis of cardiac anomalies. F-SMRI appears to be most useful in the diagnosis and management of soft tissue gastro intestinal abnormalities.

Studies of outcome after intensive care suggest that death rates do not return to normal until 2-4 years after admission. Although some questionnaire studies have reported on morbidity, little published work exists on detailed clinical recovery or longer term residual effects of critical illness. The recovery process may present serious physical, psychological, and social problems for both patients and their families, and these may last for months or years. Although patients who have been in intensive care have often been extremely ill, been at high risk of death, and received care costing tens of thousands of pounds, detailed follow up and targeted support are still rare. The 5 year mortality rate in intensive care patients is over 3 times that of the general population. However at 2 year survival rates are parallel. Adapted from Niskanen M et al. Crit Care Med 1996;24:1962-7. Patients on mechanical ventilation are usually discharged from the intensive care unit to the ward when they can breathe unaided. However, several physical problems may still remain. Although these may not be serious enough to keep the patient in intensive care, if left untreated they could lead to readmission. Intensive care staff should therefore follow patients' progress on the ward for a few days to monitor recovery of multisystem disease and assure good continuity of care. #### Examples of physical disorders after intensive care The commonest physical problem reported by intensive care patients is severe weakness and fatigue. Patients in intensive care …

Background: Although rates vary across studies, research in recent years shows that prevalence of post-traumatic stress disorder (PTSD) following intensive care unit (ICU) can be high. Presently no screening tool assessing all three PTSD symptom categories has been validated in ICU patients. The aim of the study was to conduct a preliminary validation of such a measure, the UK- Post-Traumatic Stress Syndrome 14-Questions Inventory (UK-PTSS-14). Methods: A case series cohort study performed at two ICUs in two UK district general hospitals. The UK-PTSS-14 was administered at three time-points (4-14 days, 2 months and 3 months post-ICU discharge). At time-point three participants also completed the Post-traumatic Stress Diagnostic Scale (PDS) and the Impact of Events Scale (IES). Results: Forty-four patients completed the 3-month follow up. The UK-PTSS-14 was internally reliable at all three time-points (Cronbach's α= 0.89, 0.86 and 0.84, respectively). Test-retest reliability was highest between time-points two and three (ICC = 0.90). Concurrent validity at time-point three was high against the PDS (r = 0.86) and the IES (r = 0.71). Predictive validity was highest at time-point two (r = 0.85 with the PDS and r = 0.71 with the IES). Receiver operator characteristic curve analysis suggested the highest levels of sensitivity (86%) and specificity (97%) for diagnosis of PTSD were at time-point two, with an optimum decision threshold of 45 points. Conclusion: This preliminary validation study suggests that the UK-PTSS-14 could be reliably used as a screening instrument at 2 months post-discharge from the ICU to identify those patients in need of referral to specialist psychological services.

Noise may be defined simply as “unwanted sound” [1]. The World Health Organization (WHO) recommends that the average background noise in hospitals should not exceed 30 A weighted decibels (dB[A]), and that peaks during the night-time should be less than 40 dB(A) [1]. Noise in hospitals and particularly in intensive care units (ICUs), frequently exceeds these values [2, 3, 4]. The United States Environmental Protection Agency in fact defines noise as “any sound that may produce an undesired physiological or psychological effect in an individual or group”. Noise affects both staff and patients. It may impede concentration and cognitive function [5, 6]. It interferes with effective communication and may thus increase the risk of accidents [5, 7]. The critically ill are particularly sensitive to the disruption of sleep by noise [8]. In addition, and especially for the elderly and hard of hearing, noise may hinder communication and impair understanding of their environment. It may also potentially contribute to the abnormal thought processes and behavior associated with ICU delirium [9].

Exercise-associated hyperthermia is routinely cited as the signal responsible for inducing an increased production of heat shock proteins (HSPs) following exercise. This hypothesis, however, has not been tested in human skeletal muscle. The aim of the present study was to therefore investigate the role of increased muscle and core temperature in contributing to the exercise-induced production of the major HSP families in human skeletal muscle.Seven physically active males underwent a passive heating protocol of 1 h duration during which the temperature of the core and vastus lateralis muscle were increased to similar levels to those typically occurring during moderately demanding aerobic exercise protocols. One limb was immersed in a tank containing water maintained at approximately 45 degrees C whilst the contra-lateral limb remained outside the tank and was not exposed to heat stress. Muscle biopsies were obtained from the vastus lateralis of both legs immediately prior to and at 48 h and 7 days post-heating.The heating protocol induced significant increases (P0.05) in rectal (1.5 +/- 0.2 degrees C) and muscle temperature of the heated leg (3.6 +/- 0.5 degrees C). Muscle temperature of the non-heated limb showed no significant change (P0.05) following heating (pre: 36.1 +/- 0.5, post: 35.7 +/- 0.2 degrees C). Heating failed to induce a significant increase (P0.05) in muscle content of HSP70, HSC70, HSP60, HSP27, alphaB-crystallin, MnSOD protein content or in the activity of superoxide dismutase and catalase.These data demonstrate that increases in both systemic and local muscle temperature per se do not appear to mediate the exercise-induced production of HSPs in human skeletal muscle and suggest that non-heat stress factors associated with contractile activity are of more importance in mediating this response.

Background. Increased oxidative stress may play a role in morbidity and mortality of patients with renal failure. Most studies have examined serum markers of oxidation, but it is unclear whether oxidative stress is involved in skeletal muscle atrophy. Methods. This study examined markers of oxidative stress in the skeletal muscle of 10 haemodialysed patients and 10 control subjects. Biopsies from the quadriceps femoris were analysed for reduced and oxidized glutathione, protein thiols, malonaldehyde and heat shock proteins (HSP27, HSP60 and HSP70), superoxide dismutase and catalase activities. A novel microdialysis procedure was used to examine hydroxyl radical activity in the interstitial fluid of the tibialis anterior. Results. Patients had muscle atrophy with a reduced diameter of both type I and II fibres (by 15 and 20%, respectively). Muscle microdialysates contained 2,3and 2,5-dihydroxybenzoates formed from salicylate indicating hydroxyl radical activity, with no differences between patients and control subjects. Muscle protein thiol and oxidized glutathione contents were unchanged in patients, but malonaldehyde content was reduced. In contrast, total muscle glutathione and heat shock protein contents were increased. Muscle superoxide dismutase activity was unchanged, but catalase activity was reduced in patients. Conclusions. The muscle of patients undergoing haemodialysis undergoes some adaptive responses in total glutathione content, heat shock protein content and catalase activity that are potentially related to chronic oxidative stress. However, there is no evidence of gross oxidation, nor any clear relationship between oxidative stress and muscle fibre atrophy, arguing against a direct role of oxidants in the degenerative processes.

Ageing is associated with a progressive decline of muscle mass, strength, and quality, a condition known as sarcopenia. Due to the progressive ageing of western populations, age-related sarcopenia is a major public health problem. Several possible mechanisms for age-related muscle atrophy have been described; however the precise contribution of each is unknown. Age-related muscle loss is thought to be a multi-factoral process composed of events such as physical activity, nutritional intake, oxidative stress, inflammatory insults and hormonal changes. There is a need for a greater understanding of the loss of muscle mass with age as this could have a dramatic impact on the elderly and critically ill if this research leads to maintenance or improvement in functional ability. This review aims to outline the process of skeletal muscle degeneration with ageing, normal and aberrant skeletal muscle regeneration, and to address recent research on the effects of gender and sex steroid hormones during the process of age-related muscle loss.

Purpose of review We know that adequate nutritional support is essential in the treatment of critically ill patients, because it can, if applied appropriately, improve the clinical outcome. Increasing evidence seems to suggest that malnutrition itself is a predictor of poor outcome in intensive care, and significant underfeeding during intensive care stay increases the risk of bloodstream infections. The purpose of this review is to highlight recent advances in enteral nutrition in the critically ill adult patient. Recent findings Recent studies suggest that tight glycaemic control is associated with improved outcome. Enteral feeding should be encouraged, using simple feeding protocols, and started early if safe to do so. Gastric residual volumes do not correlate with the risk of aspiration, and therefore should be used with caution in feeding protocols. Conflicting evidence exists for supplementation with antioxidant and immunonutrition in the critically ill. Glutamine and fish oil/borage oil should be considered for burns patients and patients with adult respiratory distress syndrome, respectively. Summary This review offers information regarding the latest developments in nutritional support via the enteral route. Further research is needed to clarify the role of enteral supplements such as antioxidants and 'immune modulating substances'.

In recent years, evidence has started to emerge of the impact on patients of their experiences while they were critically ill on an intensive care unit (ICU). Numerous studies in the past had shown that patients’ recall for their time on the ICU was often fragmentary and that a significant number of patients reported remembering delusional memories, such as hallucinations and nightmares [1]–[4]. However, the effect of such distorted memories on the patients’ psychological health during their recovery had, until recently, not been examined. It is only with the advent of critical care follow-up that the struggle that some patients have coming to terms with their memories for ICU has become clear 5.

Glutamine has many important metabolic roles that may protect or promote tissue integrity and enhance the immune system. The normal abundance of glutamine has meant that it has not been considered necessary to include glutamine in traditional parenteral feeds. However, low plasma and tissue levels of glutamine (Gln) in the critically ill suggest that demand may exceed endogenous supply. A relative deficiency of glutamine in such patients could compromise recovery, result in prolonged illness, and an increase in late mortality. The few percent of the most critically ill intensive care patients who are unable to tolerate enteral nutrition are especially at risk since they have increased demands for glutamine yet lack an exogenous supply. Such patients undergo considerable skeletal muscle wasting compromising glutamine supply further. In a prospective, randomised double blind clinical study of 84 patients with a high mortality due to multiple organ failure requiring parenteral feeding a significant improvement in six-month survival was observed in the group supplemented with glutamine 24/42 versus isonitrogenous, isoenergetic control 14/42, P = 0.049.

Enteral nutrition (EN) is the mainstay of nutrition delivery within intensive care seeking to capitalise on its benefits for the gastrointestinal tract and associated immune system, but this has brought new challenges in delivery to the sick. The hoped for benefit has led to the mistaken belief by some that parenteral nutrition (PN) is no longer required. However, a greater appreciation of the risks of EN delivery in the sick patient combined with improvements in PN formulation and use help explain why PN is not as risky as some have believed. Real outcome benefits have been described with the new glutamine containing PN formulations. PN remains important in the presence of gastrointestinal feed intolerance or failure.

PURPOSE OF REVIEW Although enteral nutrition is now the mainstay of nutrition delivery within intensive care, there is a blind faith in its benefits and a disregard of its risks. This has led to the belief that parenteral nutrition is no longer required as it is fraught with risks to the patient. This review attempts to dispel these myths and compares and contrasts the risks of enteral nutrition with those of parenteral nutrition in the critically ill. RECENT FINDINGS A greater appreciation of the failings and risks associated with the delivery of enteral nutrition combined with improvements in the formulation and use of parenteral nutrition help explain why parenteral nutrition is not as risky as some have believed. Recent evidence has suggested that enteral nutrition in a few selected circumstances may even carry a higher mortality risk. Real outcome benefits have been described with the new glutamine-containing parenteral nutrition formulations. SUMMARY Parenteral nutrition remains a valuable yet challenging weapon in our therapeutic armoury in the presence of gastrointestinal feed intolerance or failure. However, it should be used wisely and not indiscriminately because the majority of intensive care unit patients with a fully functional gastrointestinal tract may be fed safely with enteral nutrition.

“Death by parenteral nutrition” was the title of the controversial editorial published in the June issue of Intensive Care Medicine by P.E. Marik and M. Pinsky [1]. One might believe that a real event was being described by the authors. Imagine our astonishment, which quickly turned to dismay, when we read the words: “…a poison or toxin is a substance that through its chemical action usually kills, injures or impairs an organism… and by this definition TPN meets all criteria of a poison/toxin, in the critically ill patient receiving parenteral nutrition.” We are surprised and perturbed that the authors have missed some important issues regarding the nutrition of patients in intensive care units (ICUs), exchanging sensationalism for sound scientific discussion.

How nutritional therapy may affect real clinical outcomes is not readily apparent from a superficial reading of current data. Despite great claims in reducing infectious incidence, many studies show little difference in meaningful clinical outcomes. This has led to confusion over the role of nutrition and nutrition practice in intensive care. However, the role that nutrition plays in preventing infection and later how nutrition aids long-term recovery perhaps explain many of the misconceptions and difficulty in understanding the evidence. Encouraging new evidence is starting to show that outcome can be improved by implementing relatively simple therapies well that have an impact on nutrition and metabolic control.

Infection and sepsis remain major challenges in the critically ill. How nutritional therapy can effect real clinical outcomes is not easily apparent from the clinical data. Despite reducing infectious incidence, many studies show little difference in meaningful clinical outcomes.Confusion over the role that nutrition and nutrition practice in intensive care plays in preventing infection, and later how nutrition aids recovery from sepsis perhaps explains many of the misconceptions and difficulties with the evidence.Encouraging new evidence will help our decision making and shows that outcome can be improved by performing relatively simple therapies well.

In the care of the critically ill patient a concept termed “immunonutrition” has developed to imply a nutritional formulation that promotes or beneficially modulates the immune system. A number of nutrients have come to be known as immunonutrients of which glutamine, arginine, ornithine–a–ketoglutarate (OKG) and w-3 fatty acids have been the most extensively studied, but the list could also include nucleotides, trace minerals such as selenium, or even probiotic bacteria. This short review, predominantly focusing on amino acids, discusses what evidence exists on whether the route of administration of nutrients can effect their clinical action.

Previous studies have reported that oxidizing free radical species are generated during exercise, and there has been considerable interest in the potential effects of these on exercising tissues. We hypothesized that contracting skeletal muscle was a major source of oxidizing free radical species and that untrained skeletal muscle would adapt to the oxidative stress of a single short period of contractile activity by upregulation of the activity of cytoprotective proteins in the absence of overt cellular damage. Fifteen minutes of aerobic contractile activity was found to induce a rapid release of superoxide anions from mouse skeletal muscle in vivo, and studies with contracting cultured skeletal muscle myotubes confirmed that this was due to release from myocytes rather than other cell types present within muscle tissue in vivo. This increased oxidant production caused a rapid, transient reduction in muscle protein thiol content, followed by increases in the activities of superoxide dismutase and catalase and in content of heat shock proteins. These changes occurred in the absence of overt damage to the muscle cells.

Glutamine, a non-essential amino acid, is widely abundant in the body and in the food we eat. In times of stress it is released from skeletal muscle and acts as an interorgan nitrogen and carbon transporter. It is an important energy source directly to many cells and indirectly through glycogen metabolism. It is fundamental for protein synthesis, where it donates nitrogen for the synthesis of purines, pyrimidines, nucleotides and amino sugars, and is a precursor for the synthesis of the major antioxidant, glutathione. The kidney, liver, small intestine and cells of the immune system all use glutamine. Over the long term, the liver and immune systems predominate and use glutamine for synthetic processes and immune modulation.

Writing your first paper for a peer reviewed journal is a fairly daunting prospect. One stepping stone is to submit an abstract for presentation at a national or international conference.

New ways of approaching sedation and analgesia are being considered in our endeavour to improve our management of the ventilated patient. Long-term psychological problems are not insignificant and before we can assume benefit or harm of any new approach we must not delude ourselves by using sampling methods that can miss those patients most at risk.

Kuper and colleagues’ non-randomised before and after project merely tries to reproduce the outcomes of previous randomised trials.1 To create a study that does not advance knowledge of goal directed fluid treatment in major surgery seems to be nonsensical. Although this study is billed as a quality improvement report, …

Candida infections are an important cause of nosocomial infection that increase with time in intensive care. This may be related to a progressive state of hypo-immunity. Glutamine (gln) is an important nutrient for the immune system and has been shown to enhance the helper T subset 1 (Th1) lymphocyte responses and cell-mediated immunity.1 We report the incidence of bacterial and fungal infection that occurred during a randomized treatment study of glutamine supplemented parenteral nutrition (PN) versus a matched control parenteral feed in ventilated ICU patients unable to tolerate enteral feeding.2 Prospectively throughout the study the microbiologists attending the ICU collected microbiological data on all cultures obtained from ICU patients and any treatment decisions in laboratory notebooks. Data on those patients who received at least 5 days of parenteral nutrition were later extracted and analysed blind to the randomisation by one of the authors (KA). The frequency of infective incidents, types of organisms and types of infections was related to feed type and outcome at 28 days of discharge from ICU. Fifty-two of the original 84 randomized patients received parenteral nutrition for more than 5 days. Sepsis was the most frequent diagnosis, with gastrointestinal disease accounting for 12/25 gln-PN and 10/27 control-PN respectively. Nine of 25 gln-patients and 16/27 control-patients died in ICU or within 28 days of discharge from ICU. In the first 5 days of TPN there were 14 glnvs 12 control infective events, compared with 23 glnvs 31 control infective events during the period after 5 days TPN, or post TPN period on ICU (3 glnvs 7 control). There was no difference in the total number of Gram-positive or Gram-negative organisms isolated. Only four patients in the glutamine group developedCandida infections and none died while nine control patients developedCandida infections and six died (P = 0.07, Fischer's exact test) (Table 38). Any post hoc sub-group analysis must be interpreted with caution, especially with small numbers. However selecting a minimum of 5 days we believe is valid to show a nutritional effect. Immune dysfunction is a feature of a prolonged ICU stay and therefore any effect will only be shown in such patients. These clinical observations with a reduction in incidence and death among the patients withCandida infections suggest that glutamine may exert profound immune benefits in long stay critically ill patients who are dependent on parenteral nutrition.

The aim of this study was to look at the proportion of relatives still anxious at 2 and 6 months post ICU discharge and the incidence of post traumatic stress disorder (PTSD). Anxiety amongst relatives of intensive care (ICU) patients is understandable while patients’ remain critically ill and 60% of relatives remain anxious at 2 weeks post ICU discharge.1 However the longer term psychological consequences of this degree of prolonged stress have not been examined. The closest relative of recovering ICU patients was approached once it was clear the patient was recovering and expected to survive to 6 months. Anxiety was assessed using the Hospital Anxiety and Depression Scale (HAD) and vulnerability to PTSD using the Impact of Event Scale (IES). Fifty-four ICU patients and their closest relative were interviewed at 2 months, but only 38 relatives completed questionnaires at 6 months. All the patients had been intubated and had had an ICU stay ≥48 h with a median APACHE II score 16. While the level of anxiety amongst relatives was reduced from that seen at 2 weeks a third still remained very anxious at 2 and 6 months (see Table 13). IES scores at 6 months were predicted by the IES scores at 2 months and anxiety at 2 weeks and at 2 months (ANOVAP = 0.0001, 0.007, 0.05 respectively). Of the 20 relatives with high IES scores at 6 months, all reported intrusive memories of ICU and avoided reminders of the experience. All these relatives had been very anxious at 2 weeks post ICU; however 60% of relatives were anxious at this point. To increase the predictive power relatives with HAD anxiety scores of >13 at 2 weeks were examined; of these 12 had high IES scores at 6 months and three did not. This study suggests that anxiety levels amongst close relatives of ICU patients remains high for several months after discharge from ICU. The predictive power of early anxiety, particularly HAD scores >13, and the IES at 2 months for later psychological morbidity could allow the targeting of an intervention, such as counselling, with the aim of preventing the development of established PTSD in relatives of ICU patients.

As intensive care moves into its second half century, we are increasingly aware that severe global weakness is a significant debility after a prolonged intensive care unit (ICU) stay, impacting significantly on the pace and degree of recovery and return to former functional status. ICU-acquired weak

To the Editor:We read with great interest the article by Knowles and Tarrier (1). Although we are in favor of using a diary outlining the patients stay, which is written by staff with the help of the relatives, as therapy in their recovery we are mindful of the study’s small size and very short-term

Skeletal muscle wasting is commonly observed in critically-ill patients and has been attributed to catabolic fibre atrophy and to neuropathy. This study describes the occurrence of a necrotizing myopathy in 15 out of 31 critically-ill patients who had percutaneous biopsies taken from the tibialis anterior muscles. While most cases showed necrosis of isolated fibres, 5 of the 12 patients who had serial biopsies showed progressive necrosis of up to 95 per cent of the fibres. One other case showed infarction and one case had staphylococcal vasculitis. Atrophy of type 1 and/or type 2 fibres was documented by morphometry in 12 cases. Myoglobin-containing casts were demonstrated immunohistochemically in renal tubules on either biopsy or necropsy material in 5 out of 7 cases. The presence of muscle necrosis was a clinically unexpected finding which may contribute to weakness, complicate the interpretation of tissue biochemistry and energy balance studies, and potentiate renal failure. The necrosis is probably multifactorial in origin, with ischaemia and sepsis contributing factors.

Normal human placental metabolism has been studied in vivo by image localised 31P magnetic resonance spectroscopy in 13 women with anterior placentas; five, however, were too fat for useful spectral signals to be obtained. Magnetic resonance spectra of good quality which were considered to have arisen from the placenta were obtained from seven women with uncomplicated pregnancies (median gestational age 35 weeks, range 28-39). One other woman had a twin pregnancy in which one fetus had died a few days before. The phosphodiester signal from the placenta of the dead fetus was outside the 95% confidence intervals for normal placentas, suggesting that this technique may potentially be useful in the assessment of placental function.

Magnetic resonance imaging has potential as an imaging technique in obstetrics. Its application has been limited by the amount of image degradation that occurs as a result of fetal movement during the long imaging times. By use of a fast-scan imaging technique good images are obtained of fetal anatomy in 3 to 14 seconds per image, depending on the setting used. Different organs could be visualized by varying the setting. Magnetic resonance imaging complements the role of ultrasonography in fetal visualization. It also allows clear fetal imaging in such high-risk situations as maternal obesity and oligohydramnios, where it may be difficult to produce clear images by ultrasonography. This technique will allow wider application of magnetic resonance imaging in obstetrics and give additional information about the developing fetus.

The application of magnetic resonance techniques in the assessment of fetal growth, fetal growth patterns and fetal health was assessed. Eighty-four sets of fetal images were obtained using a fast-scan magnetic resonance imaging technique. Measurements were made of fetal subcutaneous fat thickness, uterine cavity length and width, fetal and uterine cross-sectional areas and fetal volume. Fetal area and fetal volume measurements were found to correlate well with birth weight. Measurement of subcutaneous fat thickness may prove to be a means of differentiating between those fetuses who are constitutionally as opposed to pathologically large or small. Thirteen women had additional spectroscopic studies carried out. Twelve of the women had normal pregnancies. One woman had a twin pregnancy in which one twin died. 31P phosphorus spectra were obtained from seven of the normal pregnancies. In the remainder, the depth of the abdominal wall prevented spectra being obtained from the placenta. Differences in phosphorus metabolites were obtained from the placenta of the dead twin compared to those from the healthy pregnancies.

Hallucinations and paranoid delusions are recognised complications of critical illness. However, the occurrence of Capgras syndrome, in response to critical illness, where patients are convinced that doubles have replaced close family has not been described in the literature. There have been isolated case histories in the literature in response to medical procedures or illness but mostly in patients suffering from schizophrenia. A 42 year old woman was admitted to the intensive care unit (ICU) with pneumonia, following extensive surgery for a squamous cell carcinoma, secondary to Crohns disease. She had no history of previous head injury, cerebro-vascular problems or psychiatric disorder. She reported having memories of all her family, with the exception of her mother, being replaced by aliens while she was on the ICU. The delusion was only diagnosed once it had resolved and the patient was able to talk, and this highlights the difficulty of diagnosing delusions while patients are still intubated and unable to verbalise their concerns. It has been suggested that a defect in the ability to recognise the emotional significance of the face lies at the root of Capgras syndrome.

Patients receiving total parenteral nutrition (TPN) are at high risk for bloodstream infections (BSI). The notion that intravenous calories and glucose lead to hyperglycemia, which in turn contributes to BSI risk, is widely held but is unproven. We therefore sought to determine the role that hyperglycemia and parenteral calories play in the development of BSI in hospitalized patients receiving TPN.Two hundred consecutive patients initiated on TPN between June 2004 and August 2005 were prospectively studied. Information was collected on patient age, sex, admission diagnosis, baseline laboratory values, intensive care unit (ICU) status and indication for TPN. Patients in the ICU were managed with strict glycemic control, whereas control on the general ward was more liberal. The maximum blood glucose level over each 8-hour period was recorded, as were parenteral daily intake, enteral daily intake and total daily caloric intake. The primary outcome measure was the incidence of BSI. Additional endpoints were ICU length of stay, hospital length of stay and mortality.A total of 78 patients (39%) developed at least one BSI, which were more common in ICU patients than in other hospitalized patients (60/122 patients versus 18/78 patients; P0.001). Maximum daily blood glucose concentrations were similar in patients with BSI and in patients without BSI (197 mg/dl versus 196 mg/dl, respectively). Patients with BSI received more calories parenterally than patients without BSI (36 kcal/kg/day versus 31 kcal/kg/day, P = 0.003). Increased maximum parenteral calories, increased average parenteral calories, and treatment in the ICU were strong risk factors for developing BSI. There was no difference in mortality between patients with and without BSI.Increased parenteral caloric intake is an independent risk factor for BSI in patients receiving TPN. This association appears unrelated to hyperglycemia. Based upon our observations, we suggest that parenteral caloric intake be prescribed and adjusted judiciously with care taken to account for all intravenous caloric sources and to avoid even short periods of increased intake.

Recent referrals to our intensive care unit have led us to question the indication for morphine in acute pulmonary oedema. Acute pulmonary oedema is a common, life-threatening emergency. Appropriate prompt therapy can provide rapid improvements in symptoms by reducing pre-load and after-load, or increasing myocardial contractility. Oxygen, loop diuretics, …