P001 - Sepsis impairs the capillary response within hypoxic capillaries and decreases erythrocyte oxygen-dependent ATP efflux

The appropriate caloric goal for critically ill adults is unclear. We evaluated the effect of restriction of nonprotein calories (permissive underfeeding), as compared with standard enteral feeding, on 90-day mortality among critically ill adults, with maintenance of the full recommended amount of protein in both groups. At seven centers, we randomly assigned 894 critically ill adults with a medical, surgical, or trauma admission category to permissive underfeeding (40 to 60% of calculated caloric requirements) or standard enteral feeding (70 to 100%) for up to 14 days while maintaining a similar protein intake in the two groups. The primary outcome was 90-day mortality. Baseline characteristics were similar in the two groups; 96.8% of the patients were receiving mechanical ventilation. During the intervention period, the permissive-underfeeding group received fewer mean (±SD) calories than did the standard-feeding group (835±297 kcal per day vs. 1299±467 kcal per day, P<0.001; 46±14% vs. 71±22% of caloric requirements, P<0.001). Protein intake was similar in the two groups (57±24 g per day and 59±25 g per day, respectively; P=0.29). The 90-day mortality was similar: 121 of 445 patients (27.2%) in the permissive-underfeeding group and 127 of 440 patients (28.9%) in the standard-feeding group died (relative risk with permissive underfeeding, 0.94; 95% confidence interval [CI], 0.76 to 1.16; P=0.58). No serious adverse events were reported; there were no significant between-group differences with respect to feeding intolerance, diarrhea, infections acquired in the intensive care unit (ICU), or ICU or hospital length of stay. Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount of nonprotein calories. (Funded by the King Abdullah International Medical Research Center; PermiT Current Controlled Trials number, ISRCTN68144998.)

Rationale: The optimal nutritional strategy for critically ill adults at high nutritional risk is unclear. Objectives: To examine the effect of permissive underfeeding with full protein intake compared with standard feeding on 90-day mortality in patients with different baseline nutritional risk. Methods: This is a post hoc analysis of the PermiT (Permissive Underfeeding versus Target Enteral Feeding in Adult Critically Ill Patients) trial. Measurements and Main Results: Nutritional risk was categorized by the modified Nutrition Risk in Critically Ill score, with high nutritional risk defined as a score of 5–9 and low nutritional risk as a score of 0–4. Additional analyses were performed by categorizing patients by body mass index, prealbumin, transferrin, phosphate, urinary urea nitrogen, and nitrogen balance. Based on the Nutrition Risk in Critically Ill score, 378 of 894 (42.3%) patients were categorized as high nutritional risk and 516 of 894 (57.7%) as low nutritional risk. There was no association between feeding strategy and mortality in the two categories; adjusted odds ratio (aOR) of 0.84 (95% confidence interval [CI], 0.56–1.27) for high nutritional risk and 1.01 (95% CI, 0.64–1.61) for low nutritional risk (interaction P = 0.53). Findings were similar in analyses using other definitions, with the exception of prealbumin. The association of permissive underfeeding versus standard feeding and 90-day mortality differed when patients were categorized by baseline prealbumin level (≤0.10 g/L: aOR, 0.57 [95% CI, 0.31–1.05]; >0.10 and ≤0.15 g/L: aOR, 0.79 [95% CI, 0.42–1.48]; >0.15 g/L: aOR, 1.55 [95% CI, 0.80, 3.01]; interaction P = 0.009). Conclusions: Among patients with high and low nutritional risk, permissive underfeeding with full protein intake was associated with similar outcomes as standard feeding.

Objective: The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Design: This was a pre-post rapid response team implementation study. Setting: Tertiary care academic center in Saudi Arabia. Patients: A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated. Intervention: The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs. Measurements and Main Results: The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53–0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85–0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78–0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95–3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74–0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66–0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72–0.99; p = 0.04). Conclusion: The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

In the United States, 1 in 5 deaths occurs in the intensive care unit (ICU).¹ Although it is not clear that more aggressive care always results in better outcomes, it is difficult to identify which patients will ultimately benefit from intensive care. Clinicians find it stressful to prognosticate.² Although some studies have suggested that physicians can offer reasonable predictions of survival,³ others disagree, suggesting that clinicians are wrong half the time in predicting who will survive to hospital discharge.^4,5 Substantial variability exists between experienced intensivists in providing prognosis for the same patient.⁶ Differences in opinion about appropriateness of care for a perceived prognosis contribute to clinician burnout⁷ and may contribute to doubt felt by patients and surrogates.⁸ Lack of objective data on prognosis may make shared decision making challenging.

Cirrhotic patients are characterized by a decreased synthesis of coagulation and anticoagulation factors. The coagulopathy of cirrhotic patients is considered to be auto-anticoagulation. Our aim was to determine the incidence and predictors of venous thromboembolism (VTE) and examine the practice of deep venous thrombosis (DVT) prophylaxis among hospitalized cirrhotic patients.