Background

Previous studies have shown a good agreement between central venous pressure (CVP) measurements from catheters placed in superior vena cava and catheters placed in the abdominal cava/common iliac vein. However, the influence of intra-abdominal pressure on such measurements remains unknown.

Methods

We conducted a prospective, observational study in a tertiary teaching hospital. We enrolled patients who had indwelling catheters in both superior vena cava (double lumen catheter) and femoroiliac veins (dialysis catheter) and into the bladder. Pressures were measured from all the sites, CVP, femoroiliac venous pressure (FIVP), and intra-abdominal pressure.

Results

A total of 30 patients were enrolled (age 62 ± 14 years; SAPS II 62 (52–76)). Fifty complete sets of measurements were performed. All of the studied patients were mechanically ventilated (PEP 3 cmH20 (2–5)). We observed that the concordance between CVP and FIVP decreased when intra-abdominal pressure increased. We identified 14 mmHg as the best intra-abdominal pressure cutoff, and we found that CVP and FIVP were significantly more in agreement below this threshold than above (94% versus 50%, P = 0.002).

Conclusions

We reported that intra-abdominal pressure affected agreement between CVP measurements from catheter placed in superior vena cava and catheters placed in the femoroiliac vein. Agreement was excellent when intra-abdominal pressure was below 14 mmHg.

Background

We assessed the potential impact of infusion tubing on blood glucose imbalance in ICU patients given intensive insulin therapy (IIT). We compared the incidence of blood glucose imbalance in patients equipped, in a nonrandomized fashion, with either conventional tubing or with a multiport infusion device.

Methods

We retrospectively analyzed the nursing files of 35 patients given IIT through the distal line of a double-lumen central venous catheter. A total of 1389 hours of IIT were analyzed for occurrence of hypoglycemic events [defined as arterial blood glucose below 90 mg/dL requiring discontinuation of insulin].

Results

Twenty-one hypoglycemic events were noted (density of incidence 15 for 1000 hours of ITT). In 17 of these 21 events (81%), medication had been administered during the previous hour through the line connected to the distal lumen of the catheter. Conventional tubing use was associated with a higher density of incidence of hypoglycemic events than multiport infusion device use (23 vs. 2 for 1,000 hours of IIT; rate ratio = 11.5; 95% confidence interval, 2.71–48.8; p < 0.001).

Conclusions

The administration of on-demand medication through tubing carrying other medications can lead to the delivery of significant amounts of unscheduled products. Hypoglycaemia observed during IIT could be related to this phenomenon. The use of a multiport infusion device with a limited dead volume could limit hypoglycemia in patients on IIT.

Introduction

The primary aim was to measure the amount of nutrients required, prescribed and actually administered in critically ill patients. Secondary aims were to assess adherence to clinical practice guidelines, and investigate factors leading to non-adherence.

Methods

Observational, multicenter, prospective study, including 203 patients in a total of 19 intensive care units in France. The prescribed calorie supply was compared with the theoretical minimal required calorie intake (25 Kcal/Kg/day) and with the supply actually delivered to the patient to calculate the ratio of calories prescribed/required and the ratio of calories delivered/prescribed. Clinical factors suspected to influence enteral nutrition were analyzed by univariate and multivariate analysis.

Results

The median ratio of prescribed/required calories per day was 43 [37-54] at day 1 and increased until day 7. From day 4 until the end of the study, the median ratio was > 80%. The median ratio of delivered/prescribed per day was > 80% for all 7 days from the start of enteral nutrition. Among the variables tested (hospital type, use of a local nutrition protocol, sedation, vasoactive drugs, number of interruptions of enteral nutrition and measurement of gastric residual volume), only measurement of residual volume was significant by univariate analysis. This was confirmed by multivariate analysis, where gastric residual volume measurement was the only variable independently associated with the ratio of delivered/prescribed calories (OR = 1.38; 95%CI, 1.12-2.10, p = .024).

Conclusions

The translation of clinical research and recommendations for enteral nutrition into routine bedside practice in critically ill patients receiving mechanical ventilation was satisfactory, but could probably be improved with a multidisciplinary approach.

Objective

1/ To evaluate if empirical antibiotic prescription on admission to our intensive care unit (ICU) respects the local recommendations for antibiotic prescription and to identify predictors of nonadherence to these guidelines. 2/ To assess whether nonadherence to the guidelines is associated with increased in-hospital mortality due to the initial infection.

Materials and methods

This was a prospective six-month observational study performed in a 14-bed medical ICU. Patients were included if they received curative antibiotic therapy on admission. Respect of the local treatment recommendations was evaluated according to adherence to the local empirical guidelines defined in a 80-page booklet which is given in our hospital to every physician.

Results

Among 132 antibiotic prescriptions, 21 (16%) were unjustified (absence of infection), 17 (13%) were microbiologically documented at admission, and nine (7%) were given for infections from unknown origin. Among the 85 (64%) empirical prescriptions that could be evaluated for adherence to local recommendations, nine (11%) were inappropriate and 76 (89%) appropriate. In univariate analysis hospital-acquired infection was the sole predictor of inappropriate treatment (p = 0.0475). Independent predictors of in-hospital mortality due to the initial infection were inappropriate empirical treatment (odds ratio [OR] = 14.64, 95% confidence interval [CI]: 2.17–98.97; p = 0.006), prescription of fluoroquinolones (OR = 8.22, 95% CI: 1.88–35.95; p = 0.005) and a higher Simplified Acute Physiology Score II score (per one-point increment (OR = 1.04, 95% CI: 1.01–1.07; p = 0.02).

Conclusion

Nonadherence to local empirical antibiotic therapy guidelines was associated with increased in-hospital mortality due to the initial infection.

Three women were consecutively admitted to our medical intensive care unit for thyrotoxicosis after the ingestion of dietary pills accidentally containing high levels of thyroxin. These cases were observed during an outbreak in the Paris area. Despite similar blood levels of thyroid hormones, their clinical presentation and outcome were very different. One patient developed febrile confusion and died from malignant hyperthermia. The second one had progressive confusion requiring mechanical plasma exchange therapy and had a favorable outcome. The third one had very moderate symptoms. These exceptional observations raise several issues concerning diagnosis, physiopathology and treatment of thyrotoxicosis factitia.