Jill C. Rudkowski

An evaluation of the '5 Minute Medicine' video podcast series compared to conventional medical resources for the internal medicine clerkship.

Background: ‘5 Minute Medicine’ (5MM) is a series of video podcasts, that in approximately 5 min, each explain a core objective of the internal medicine clerkship that all clinical clerks should understand. Video podcasts are accessible at www.5minutemedicine.com Aim: The aim of this study was to investigate how well received 5MM video podcasts are as an educational tool for clinical clerks to use while on call. Methods: Clinical clerks rotating through their internal medicine clerkship rotation were asked to use the 5MM video podcasts or conventional resources to prepare themselves prior to seeing patients. Questionnaires were distributed to students to determine effectiveness, appropriateness and time-efficiency of the resources students used. Results: Students almost unanimously strongly agreed or agreed that the 5MM video podcasts were effective learning tools, appropriate for clinical clerks and time-efficient, more so than conventionally used resources. The vast majority of clerks selected the 5MM videos as their preferred resource of all resources available to them. Most clerks felt the 5MM videos were better than textbooks and conventional online resources. Conclusion: Video podcasts such as the 5MM videos are welcomed as educational tools and may have a role in the future of undergraduate medical education.

TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients.

Introduction The objective of this study was to assess the safety and feasibility of in-bed cycling started within the first 4 days of mechanical ventilation (MV) to inform a future randomized clinical trial. Methods We conducted a 33-patient prospective cohort study in a 21-bed adult academic medical-surgical intensive care unit (ICU) in Hamilton, ON, Canada. We included adult patients (≥ 18 years) receiving MV who walked independently pre-ICU. Our intervention was 30 minutes of in-bed supine cycling 6 days/week in the ICU. Our primary outcome was Safety (termination), measured as events prompting cycling termination; secondary Safety (disconnection or dislodgement) outcomes included catheter/tube dislodgements. Feasibility was measured as consent rate and fidelity to intervention. For our primary outcome, we calculated the binary proportion and 95% confidence interval (CI). Results From 10/2013-8/2014, we obtained consent from 34 of 37 patients approached (91.9%), 33 of whom received in-bed cycling. Of those who cycled, 16(48.4%) were female, the mean (SD) age was 65.8(12.2) years, and APACHE II score was 24.3(6.7); 29(87.9%) had medical admitting diagnoses. Cycling termination was infrequent (2.0%, 95% CI: 0.8%-4.9%) and no device dislodgements occurred. Cycling began a median [IQR] of 3 [2, 4] days after ICU admission; patients received 5 [3, 8] cycling sessions with a median duration of 30.7 [21.6, 30.8] minutes per session. During 205 total cycling sessions, patients were receiving invasive MV (150 [73.1%]), vasopressors (6 [2.9%]), sedative or analgesic infusions (77 [37.6%]) and dialysis (4 [2.0%]). Conclusions Early cycling within the first 4 days of MV among hemodynamically stable patients is safe and feasible. Research to evaluate the effect of early cycling on patient function is warranted. Trial Registration Clinicaltrials.gov: NCT01885442

Are we meeting nutritional targets for critically ill patients

To the Editor, Critically ill patients benefit from early enteral nutrition (EN), as it promotes gastrointestinal immunity and decreases nosocomial infections. Nevertheless, crosssectional studies show that up to 40% of patients in the intensive care unit (ICU) do not receive nutrition. The objective of this report was to evaluate the time to nutritional adequacy, defined as the time to achieve at least 80% prescribed EN, and associated factors in our centre (Table). One hundred consecutive patients admitted to the ICU for more than 48 hr were included in this retrospective cohort study, and patients with absolute contraindications to EN were excluded. We compared the time to nutritional adequacy of patients who received EN with those who received EN plus parenteral nutrition (PN), and we used Cox regression analysis to determine the factors that were significantly associated with achieving adequate nutrition. Eighty percent of patients received some form of EN, and 58% received EN exclusively. Reasons for interruption of EN included awaiting confirmation of a feeding tube, gastrointestinal bleeding, awaiting procedures, potential extubation, and transition to an oral diet. The median time to initiate EN after admission was two days, and only 24% of patients received any EN within 24 hr of admission. While 7% of patients received PN exclusively, 13% received no nutrition. Patients receiving EN exclusively achieved nutritional adequacy faster than those who received combined EN and PN (4.6 vs 7.1 days, respectively; P \ 0.01). Cox regression analysis showed that age and early use of prokinetics were significantly associated with achieving adequate nutrition (hazard ratio 1.04 and 3.68; P = 0.03 and 0.02, respectively). A sensitivity analysis using backward stepwise selection produced similar estimates. This study provides a contemporary Canadian snapshot of ICU nutrition in a single institution, highlighting a discrepancy in some areas between clinical practice and published guidelines. Early use of prokinetics was significantly associated with achieving adequate nutrition. New 2013 recommendations for critical care nutrition have just been released. Based on emerging studies, combined EN and PN is not recommended, and this approach was rare in our study. Parenteral nutrition is not recommended until all strategies to maximize EN delivery have been attempted (e.g., small bowel feeding tubes, prokinetics); however, in our study, these optimal practices for EN delivery were not always initiated prior to PN. The role of combined EN and PN remains controversial. An observational study by Cahill et al. suggested that combination EN and PN provided increased calories but resulted in no difference in hospital length of stay or mortality. Observational studies suggest early PN is beneficial, but clinical guidelines are inconsistent. European societies promote PN within two days of admission, while North American guidelines suggest later PN initiation. C. M. Katsios, MD (&) S. Pizzale, MD Department of Medicine, McMaster University, Hamilton, ON, Canada

Noninvasive ventilation after extubation reduced respiratory failure and 90-day mortality in hypercapnic patients

Source Citation Ferrer M, Sellares J, Valencia M, et al. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2...