Alexander Bindels

Treatment of hypophosphatemia in the intensive care unit: a review

IntroductionCurrently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients.MethodsWe performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior.ResultsIncidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients.ConclusionsAdditional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.

Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial

IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance. OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively. INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD. MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6% (95% CI, 4.6%-6.7%) during SDD and 11.8% (95% CI, 10.3%-13.2%) during SOD (P < .001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77). CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria. TRIAL REGISTRATION trialregister.nlIdentifier: NTR1780.

The prevalence of subclinical hypothyroidism at different total plasma cholesterol levels in middle aged men and women: a need for case‐finding?

In order to determine whether screening of thyroid function is justified in patients with hypercholesterolaemia, we determined the prevalence of subclinical hypothyroidism at different levels of total plasma cholesterol in middle‐aged men and women.

Pulmonary artery wedge pressure and extravascular lung water in patients with acute cardiogenic pulmonary edema requiring mechanical ventilation

This study describe the values of pulmonary artery wedge pressure (PAWP) and the extravascular lung water (EVLW) index in patients with acute cardiogenic pulmonary edema who require mechanical ventilation. Ten consecutive patients with acute cardiogenic pulmonary edema who required mechanical ventilation were studied. Cardiac index was determined with thermodilution. Central venous pressure and PAWP were measured with a pulmonary artery catheter. EVLW index was determined with the thermal dye dilution technique, using a commercially available computer system. Measurements were made at regular preset intervals after the initiation of mechanical ventilation. PAWP was normal at baseline (11.6+/-0.9 mm Hg, range 8 to 17) and did not change. EVLW index was elevated at baseline (13.7+/-1.5 ml/ kg) and decreased to a normal value after 24 hours (8.6+/-1.2 ml/kg, p = 0.02). Concomitantly cardiac index increased from 2.61+/-0.24 to 3.61+/-0.14 L/min/m2 (p = 0.05). There was no correlation between PAWP and EVLW index. Fluid balance was +1,221+/-908 ml after 24 hours and there was a weight gain of 0.88+/-1.06 kg after 24 hours. Thus, patients with acute cardiogenic pulmonary edema requiring mechanical ventilation may have a normal PAWP after mechanical ventilation has been initiated. In a hemodynamic unstable situation, these patients may require fluid challenges to improve cardiac output, despite the presence of pulmonary edema. The pulmonary edema, measured as EVLW index, resolves rapidly when cardiac performance improves, despite positive fluid balances and weight gain in the first 24 hours.

Determinants of Tidal Volumes with Adaptive Support Ventilation : A Multicenter Observational Study

INTRODUCTION:In the present study, we investigated the behavior of adaptive support ventilation (ASV) in patients after cardiothoracic surgery. We determined tidal volumes (Vt) and factors that influence Vt with this mode of microprocessor-controlled mechanical ventilation (MV). METHODS:This was a prospective, multicenter, observational study in three Dutch intensive care units over a 5-mo period. MV data were collected during steady-state after arrival in the intensive care unit. RESULTS:Data were collected for 346 consecutive patients after cardiothoracic surgery: 262 patients weaned with ASV, and 84 patients weaned with pressure-controlled/pressure-support MV. With ASV the mean (± sd) Vt expressed per kilogram actual body weight was 7.1 ± 1.6 mL. Expressed per kilogram ideal body weight (IBW), Vt was 8.3 ± 1.5 mL. In patients with a correctly set body weight (SBW) (i.e., the IBW), Vt was 8.1 ± 1.4 mL/kg. With pressure-controlled/pressure-support-MV Vt was 7.3 ± 1.4 mL/kg IBW (P < 0.001 vs ASV). Multivariate logistic regression analysis showed Vt with ASV to be dependent on only two parameters: respiratory rate and the correctness of SBW. CONCLUSIONS:Vt with ASV seems to be dependent on two parameters: respiratory rate and the correctness of SBW. The first factor is not clinically important because respiratory rate is automatically chosen by the microprocessor. The second factor is clinically important because it is the only factor that can be influenced by the operator. Our data show the importance of setting the correct weight with ASV. With ASV, Vt are >8 mL/kg IBW in a substantial number of patients. Randomized clinical trials should be performed to compare ASV with other ventilation modes.

Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey

IntroductionUse of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians.MethodsA survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires.ResultsIn all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0).ConclusionsAlthough perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies.Trial registrationISRCTN35176830.

Notice of Retraction and Replacement: Oostdijk et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014;312(14):1429-1437.

Citation for published version (APA): Oostdijk, E. A. N., Kesecioglu, J., Schultz, M. J., Visser, C. E., de Jonge, E., van Essen, E. H. R., ... Bonten, M. J. M. (2017). Notice of Retraction and Replacement: Oostdijk et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014;312(14):1429-1437. JAMA Journal of the American Medical Association, 317(15), 15831584. DOI: 10.1001/jama.2017.1282

Extravascular lung water in patients with septic shock during a fluid regimen guided by cardiac index.

BACKGROUND To elucidate whether patients with a septic shock develop pulmonary edema in a treatment protocol in which volume loading is guided by its effect on the cardiac output, rather than by preset values of pulmonary artery wedge pressure (PAWP). METHODS 15 consecutive patients with the diagnosis of septic shock were studied in a prospective observational study. Cardiac output, PAWP and extravascular lung water index (EVLWI) were determined at regular intervals during the first 24 h of treatment. Fluid challenges were given if MAP was <80 mm Hg and/or CI was <4.5 l/min/m(2), and PAWP was <16 mm Hg. Further fluid challenges were only given if the preceding fluid challenge resulted in an increase in CI of more than 10% and PAWP was still <16 mm Hg. RESULTS EVLWI was slightly above normal (10.4+/-1.2 ml/kg) and did not change during the treatment protocol. One third of the patients had an initial PAWP>16 mmHg. In these patients, EVLWI was significantly higher than in patients with an initial PAWP <16 mm Hg (14.1+/-1.1 ml/kg versus 10.0+/-0.9 ml/kg, P=0.026). No significant correlation was found between PAWP and EVLWI. CONCLUSION In this study, patients with septic shock did not develop pulmonary edema during the first 24 h of treatment, when their fluid regimen was guided by the effects on cardiac output.

Fully automated closed-loop ventilation is safe and effective in post-cardiac surgery patients

Dear Editor, A recent Cochrane review shows that automated ventilation, like assisted support ventilation (ASV), may reduce duration of weaning, ventilation, and ICU stay [1]. An extension of ASV is the fully automated closedloop ventilating mode IntelliventASV (iASV). Minute ventilation is not only automatically calculated on the basis of ASV’s least work of breathing concept according to Otis [2], but in combination with the patients end-tidal CO2 (EtCO2). And unlike ASV, it automatically adjusts FiO2 and positive end-expiratory pressure (PEEP) on the basis of the ARDS Network PEEP-FiO2 tables to maintain a target pulse oxymetry [3]. We conducted a prospective noninferiority pilot study to determine the safety and efficacy of iASV compared to ASV and our conventional ventilation (pressurecontrolled ventilation followed by pressure support ventilation) in patients weaning on a post-anesthesia care unit (PACU). Included were low-risk post-cardiac surgery adults, suitable to wean on the PACU. Excluded were patients with a positive history of COPD Gold 3 or 4, lung surgery, and patients in shock. The ventilation mode could be changed when current ventilation was inefficient. The medical ethical committee approved the study and patients were excluded if they objected to use of their information. In total 128 patients were included and divided into three groups, conventional ventilation (n = 49), iASV (n = 53), and ASV (n = 26), based on the moment of admission at the PACU. Analysis of variance (ANOVA) between groups showed no statistically significant difference of age, BMI (kg/m), smokers, Euroscore, extracorporal circulation time, and type of cardiac surgery. Ventilation-related safety issues requiring interventions were not observed in all groups. The number of interactions was statistically significantly lower in the iASV group compared to the other groups (Fig. 1). Mechanical ventilation time, the number of reintubations, and the amount of desaturations, defined as a SpO2 lower than 85 %, showed no statistically significant differences (p [ 0.05). Fully automated closed-loop ventilation is able to mimic the dynamic process of human breathing by constantly adjusting ventilation and oxygenation depending on the individual demand. In our prospective trial we showed that full closed-loop ventilation with iASV is a safe and effective mode to ventilate, oxygenate, and wean low-risk post-cardiac surgery patients. The reduced number of interactions with the ventilator decreases workload, the risk of human errors, and may reduce inadequate ventilation time. This reduction could even be underestimated, because most physicians and nurses lacked confidence to extubate the patient directly from the new ventilation mode (iASV). Our results were consistent with previous studies comparing iASV with conventional ventilation modes [4, 5]. These studies even report a statistically significant higher percentage of acceptable and optimal ventilation time (99.5 % instead of 93 %, p \ 0.001) [4], with statistically significant lower ventilating pressures, volumes, and FiO2 in both lowand high-risk critically ill patients [4, 5]. Our non-inferiority trial confirms that iASV is as safe and efficient as conventional ventilation and ASV to ventilate and oxygenate weaning patients after cardiac surgery. However, more studies are needed in

122: PREDICTING FLUID RESPONSIVENESS IN POST-CARDIAC SURGERY PATIENTS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) APACHE-II 22 ± 11) 232 datasets (8 datasets per patient within 24h) including CI-PC and CI-uncal (ClearSight) were recorded and compared to the subsequent thermodilution-derived CI-TD (PiCCO; Pulsion, Germany). Wilcoxon-test for paired samples; Bland-Altman-analyis; SPSS 23.Results: CI-PC was not significantly different from CI-TD (4.17 ± 1.09 vs. 4.19 ± 1.08L/min*m2; p=0.257). Bias (-0.028 ± 0.56L/min*m2) and percentage-error (26.6%) were acceptable. CI-uncal (4.90 ± 1.21L/min*m2) was significantly lower compared to CI-TD (p<0.001) and provided an acceptable bias of -0.30 ± 1.04L/min*m2. However, the percentage error (51.5%) was markedly above the acceptable threshold of 30%. CI-PC (AUC 0.949; p<0.001) and CI-uncal (AUC 0.868; p=0.030) significantly predicted “CI-TD>5L/min*m2”. While “CI-TD<2.5L/min*m2” was predicted by CI-PC (0.944; p<0.001), CI-uncal was not predictive (AUC 0.676; p=0.113). Changes in CI-TD were significantly associated to changes in CI-PC (r=0.420; p<0.001) and to changes in CI-uncal (r=0.314; p<0.001). Furthermore, changes in CI-PC and changes in CI-uncal were significantly correlated (r=0.307; p<0.001). Among all 232 measurements increases and decreases in CI-TD of more than 0.5L/min*m2 were significantly predicted by changes in CIuncal (AUC 0.754; p<0.001; AUC 0.691; p=0.005). Conclusions: Calibrated CI-PC provides an assessment of CI-TD with appropriate accuracy, precision and prediction of critical thresholds. Although CI-uncalib derived by ClearSight has acceptable accuracy, precision is not appropriate with a percentage error of 51.5%. While CI-uncal predicted “CI-TD>5L/min*m2”, it failed to predict “CI-TD<2.5L/min*m2”. Despite inappropriate estimation of absolute values of CI-TD, CI-uncalib provides acceptable prediction of trends.