Reignier J.,Roche Holding AG |
Reignier J.,University of Nantes |
Mercier E.,University of Tours |
Le Gouge A.,French Institute of Health and Medical Research |
And 8 more authors.
JAMA - Journal of the American Medical Association | Year: 2013
Importance: Monitoring of residual gastric volume is recommended to prevent ventilator-associated pneumonia (VAP) in patients receiving early enteral nutrition. However, studies have challenged the reliability and effectiveness of this measure. Objective: To test the hypothesis that the risk of VAP is not increased when residual gastric volume is not monitored compared with routine residual gastric volume monitoring in patients receiving invasive mechanical ventilation and early enteral nutrition. Design, Setting, and Patients: Randomized, noninferiority, open-label, multicenter trial conducted from May 2010 through March 2011 in adults requiring invasive mechanical ventilation for more than 2 days and given enteral nutrition within 36 hours after intubation at 9 French intensive care units (ICUs); 452 patients were randomized and 449 included in the intention-to-treat analysis (3 withdrew initial consent). Intervention: Absence of residual gastric volume monitoring. Intolerance to enteral nutrition was based only on regurgitation and vomiting in the intervention group and based on residual gastric volume greater than 250 mL at any of the 6 hourly measurements and regurgitation or vomiting in the control group. Main Outcome Measures: Proportion of patients with at least 1 VAP episode within 90 days after randomization, as assessed by an adjudication committee blinded to patient group. The prestated noninferiority margin was 10%. Results: In the intention-to-treat population, VAP occurred in 38 of 227 patients (16.7%) in the intervention group and in 35 of 222 patients (15.8%) in the control group (difference, 0.9%; 90% CI, -4.8% to 6.7%). There were no significant between-group differences in other ICU-acquired infections, mechanical ventilation duration, ICU stay length, or mortality rates. The proportion of patients receiving 100% of their calorie goal was higher in the intervention group (odds ratio, 1.77; 90% CI, 1.25-2.51; P=.008). Similar results were obtained in the per-protocol population. Conclusion and Relevance: Among adults requiring mechanical ventilation and receiving early enteral nutrition, the absence of gastric volume monitoring was not inferior to routine residual gastric volume monitoring in terms of development of VAP. Trial Registration: clinicaltrials.gov Identifier: NCT0113748 ©2013 American Medical Association. All rights reserved.
Ruppe E.,University of Geneva |
Woerther P.-L.,CNRS Gustave Roussy Institute |
Barbier F.,Medical Intensive Care Unit
Annals of Intensive Care | Year: 2015
The burden of multidrug resistance in Gram-negative bacilli (GNB) now represents a daily issue for the management of antimicrobial therapy in intensive care unit (ICU) patients. In Enterobacteriaceae, the dramatic increase in the rates of resistance to third-generation cephalosporins mainly results from the spread of plasmid-borne extended-spectrum beta-lactamase (ESBL), especially those belonging to the CTX-M family. The efficacy of beta-lactam/beta-lactamase inhibitor associations for severe infections due to ESBL-producing Enterobacteriaceae has not been adequately evaluated in critically ill patients, and carbapenems still stands as the first-line choice in this situation. However, carbapenemase-producing strains have emerged worldwide over the past decade. VIM- and NDM-type metallo-beta-lactamases, OXA-48 and KPC appear as the most successful enzymes and may threaten the efficacy of carbapenems in the near future. ESBL- and carbapenemase-encoding plasmids frequently bear resistance determinants for other antimicrobial classes, including aminoglycosides (aminoglycoside-modifying enzymes or 16S rRNA methylases) and fluoroquinolones (Qnr, AAC(6′)-Ib-cr or efflux pumps), a key feature that fosters the spread of multidrug resistance in Enterobacteriaceae. In non-fermenting GNB such as Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia, multidrug resistance may emerge following the sole occurrence of sequential chromosomal mutations, which may lead to the overproduction of intrinsic beta-lactamases, hyper-expression of efflux pumps, target modifications and permeability alterations. P. aeruginosa and A. baumannii also have the ability to acquire mobile genetic elements encoding resistance determinants, including carbapenemases. Available options for the treatment of ICU-acquired infections due to carbapenem-resistant GNB are currently scarce, and recent reports emphasizing the spread of colistin resistance in environments with high volume of polymyxins use elicit major concern. © 2015, Ruppé et al.
Bardou M.,CHU de Dijon |
Quenot J.-P.,Medical Intensive Care Unit |
Barkun A.,McGill University
Nature Reviews Gastroenterology and Hepatology | Year: 2015
Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease. © 2015 Macmillan Publishers Limited. All rights reserved.
Neto A.S.,Medical Intensive Care Unit |
Schultz M.J.,University of Amsterdam
Current Opinion in Critical Care | Year: 2014
PURPOSE OF REVIEW: There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS as well. This manuscript systematically reviews recent preclinical studies of ventilation in animals with uninjured lungs, and clinical trials of ventilation in ICU patients without ARDS on the association between tidal volume size and pulmonary complications and outcome. RECENT FINDINGS: Successive preclinical studies almost without exception show that ventilation with lower tidal volumes reduces the injurious effects of ventilation in animals with uninjured lungs. This finding is in line with results from recent trials in ICU patients without ARDS, demonstrating that ventilation with lower tidal volumes has a strong potential to prevent development of pulmonary complications and maybe even to improve survival. However, evidence mostly comes from nonrandomized clinical trials, and concerns are expressed regarding unselected use of lower tidal volumes in the ICU, that is, in all ventilated critically ill patients, since this strategy could also increase needs for sedation and/or neuromuscular blockade, and maybe even cause respiratory muscle fatigue. These all then could in fact worsen outcome, possibly counteracting the beneficial effects of ventilation with lower tidal volumes. SUMMARY: Ventilation with lower tidal volumes protects against pulmonary complications, but well-powered randomized controlled trials are urgently needed to determine whether this ventilation strategy truly benefits all ventilated ICU patients without ARDS. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Hough C.L.,University of Washington |
Hough C.L.,Medical Intensive Care Unit
Current Opinion in Critical Care | Year: 2013
PURPOSE OF REVIEW: Although it has been demonstrated that physical functional impairments are common among survivors of critical illness, few studies have proven benefits of intervention. This review will discuss assessment of physical functional impairment, recent and ongoing interventional studies, and implementation of rehabilitation beginning in the ICU, hospital ward, and after hospital discharge. RECENT FINDINGS: New studies confirm challenges around measurement of physical function both during and after critical illness, and offer potential new modalities that could inform mechanism and treatment. Longitudinal cohort studies emphasize the importance of recognition and measurement of premorbid status. Although no recent studies have proven new approaches to improving physical function in survivors of critical illness, emerging data support the safety, feasibility, and cost-effectiveness of providing physical rehabilitation early in the course of critical illness. Pilot and ongoing studies hold promise for improving physical function and quality of life for future survivors of critical illness. SUMMARY: Improving physical function for survivors of critical illness will require careful application of current knowledge, as well as rigorous investigation into causes, research methodologies, and implementation of results of future interventional studies. © 2013 Wolters Kluwer Health Lippincott Williams & Wilkins.