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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Clinical characteristics and mortality of patients in the intensive care unit with and without new-onset arrhythmias

Abstract

Objective. The aims of this study were to analyze the risk factors for and types of new-onset arrhythmias in ICU (Intensive care unit), and to evaluate their impact on patient outcomes.

Methods. We studied 1051 patients who were admitted to the two general ICUs between December 2013 and February 2016. These patients were divided into two groups: patients with new-onset arrhythmias and patients without new-onset arrhythmias. We compared the risk factors, types and prognoses of new-onset arrhythmias between these two groups.

Results. New-onset arrhythmias were observed in 20.84% (n=219) of 1051 patients. The main risk factors leading to arrhythmias included age, emergency operation, past cardiovascular disease, patients with multiple systemic diseases, acute respiratory distress syndrome, severe sepsis/septic shock, acute renal dysfunction, cardiovascular disease, electrolyte disturbance, patients on ventilators, patients on vasopressors and higher Acute Physiology and Chronic Health Evaluation II scores (APACHE II score) on ICU admission. Multivariate logistic regression revealed that age, emergency operation, severe sepsis/septic shock, cardiovascular disease, electrolyte disturbance, patients on ventilators and those with higher APACHE II scores on ICU admission, were all significantly associated with new-onset arrhythmias. Arial fibrillation was the most frequent arrhythmia. ICU mortality in patients with new-onset arrhythmias was 22.37% (49 out of 219) compared with 3.61% (30 out of 832) in patients without new-onset arrhythmias (p<0.001). Among surviving patients, ICU stay for those with new-onset arrhythmias was longer than those without new-onset arrhythmias (median stay of 10 days versus 5 days, p<0.001).

Conclusion. We found a high prevalence of new-onset arrhythmias in ICU patients. Arrhythmia, especially atrial fibrillation, was a common complication in ICU patients and was associated with increasing length of ICU stay and higher mortality.

Key words: arrhythmia, intensive care unit, critical illness, mortality

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An update on muscle wasting in ICU

Abstract

Mortality rates from critical illness are decreasing worldwide, but survivors suffer from significant functional disability as a result of muscle wasting. In the short-term the functional effects are seen in increased time of mechanical ventilation, and increased length of stay. Muscle wasting is the most common complication of critical illness, occurring in 25-50% of patients. In a longitudinal observational study, daily loss of muscle mass averaged 2-3% over the first 10 days. The scale of wasting was related to the severity of organ failure and of acute lung injury.

Changes in muscle mass are underpinned by alterations in muscle protein homeostasis. In stable isotope infusion experiments, muscle protein synthesis was reduced to levels of fasted controls despite the initiation of enteral feed. Protein synthetic levels recovered variably over the first week to levels comparable to fed controls. As a result, muscle protein breakdown was increased relative to muscle protein synthesis, leading to a net catabolic state.

There is a need for secondary prevention measures to be instituted in current practise. Increased nutritional delivery cannot be recommended at this stage during acute critical illness and early mobilisation has been demonstrated to increase functional status. This is best achieved through the ABCDEF bundle. This bundle constitutes a co-ordinated package of care with sedation control to facilitate spontaneous breathing and decreasing delirium. This facilitates early mobilisation, which is currently the only preventative measure with an evidence base to decrease skeletal muscle wasting associated functional disability.

Key words: muscle wasting, critical illness, muscle mass

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Effects of enteral nutrition on clinical outcomes among mechanically ventilated and sedated patients in the pediatric intensive care unit

Abstract

Objective. To analyze the effects of enteral nutrition on outcomes and complications of critically ill children in the pediatric intensive care unit (PICU).

Design. Retrospective cohort study.

Setting. PICU in a tertiary care academic medical center.

Patients. Patients up to age 17 years who were admitted to the PICU between January 1, 2011, and December 31, 2013.

Interventions. Intubation for more than 48 hours and requiring any sedative medications. Patients with surgical contraindications to feeding were excluded.

Measures and Main Results. A total of 165 patients met inclusion criteria. Both manual review of the electronic health record and automated data capture (whenever technically feasible) were conducted. Data were collected in REDCap software and analyzed using a statistical discovery program. The mean (SD) calorie intake within the first 10 days of PICU admission was 40% (31.9%) of the prescribed calories. Only 67% of the patients had feeding initiated within 48 hours of admission. No significant difference in hospital or PICU length of stay or ventilator-free days was observed in patients who met one-third of their nutritional goals (50.3%) compared with patients who did not (49.7%). Mortality was nonsignificantly higher among patients who did not meet nutritional goals (P=.07). No association was found between higher doses of opioids or benzodiazepines and nutrition tolerance or gastrointestinal complications.

Conclusions. Early adequate enteral nutrition had no statistically significant impact on the short-term clinical outcomes of PICU patients.

Key words: critical illness, deep sedation, energy intake, pediatric intensive care unit, pediatrics, respiration, artificial

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Indications for blood transfusions in critical illness

Abstract

Transfusion of blood products should improve tissue oxygenation and reduce negative consequences of anaemia. At the same time, adverse effects of transfusion, such as infections, immunologic reactions and mistransfusion, could be deleterious. Most transfusion guidelines suggest looking at the combination of haemoglobin or haematocrit levels in addition to clinical signs in the decision making process for a blood transfusion. The problem with such indications is that the clinical evaluation may be misleading in severely ill patients and haemoglobin levels that impair oxygen delivery cannot be determined easily. Many studies attempted to establish more convenient parameters, such as oxygen saturation from mixed and central venous blood, tissue oxygen extraction and other methods. Although the results from these studies are conflicting, it appears that global oxygenation parameters are a good indicator for a blood transfusion in some categories of critically ill patients.

Key words: haemoglobin concentration, global oxygenation parameters, transfusion, critical illness

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