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Objectives To examine the effect of positive end-expiratory pressure (PEEP) on right ventricular stroke volume variation (SVV), with possible implications for the number and timing of pulmonary artery catheter thermodilution measurements. Design Prospective, clinical pilot study. Setting Academic medical center. Participants Patients who underwent volume-controlled mechanical ventilation and had a pulmonary artery catheter. Intervention PEEP was increased from 5-to-10 cmH 2 O and from 10-to-15 cmH 2 O with 10-minute intervals, with similar decreases in PEEP, from 15-to-10 cmH 2 O and 10-to-5 cmH 2 O. Measurements and Main Results In 15 patients, right ventricular parameters were measured using thermodilution at 10% intervals of the ventilatory cycle at each PEEP level with a rapid-response thermistor. Mean right ventricular stroke volume and end-diastolic volume declined during incremental PEEP and normalized on return to 5 cmH 2 O PEEP (p = 0.01 and p = 0.001, respectively). Right ventricular SVV remained unaltered by changes in PEEP (p = 0.26), regardless of incremental PEEP (p = 0.15) or decreased PEEP (p = 0.12). The coefficients of variation in the ventilatory cycle of all other thermodilution-derived right ventricular parameters also were unaffected by changes in PEEP. Conclusions This study showed that increases in PEEP did not affect right ventricular SVV in critically ill patients undergoing mechanical ventilation despite reductions in mean right ventricular stroke volume and end-diastolic volume. This could be explained by cyclic counteracting changes in right ventricular preloading and afterloading during the ventilatory cycle, independent of PEEP. Changes in PEEP did not affect the number and timing of pulmonary artery catheter thermodilution measurements. [ABSTRACT FROM AUTHOR]

Summary: Background & aims: Low handgrip strength by dynamometry is associated with increased postoperative morbidity, higher mortality and reduced quality of life. The aim of this study was to evaluate the accuracy of four algorithms in diagnosing malnutrition by measuring handgrip strength. Methods: We included 504 consecutive preoperative outpatients. Reference standard for malnutrition was defined based on percentage involuntary weight loss and BMI. Diagnostic characteristics of the handgrip strength algorithms (Álvares-da-Silva, Klidjian, Matos, Webb) were expressed by sensitivity, specificity, positive and negative predictive value, false positive and negative rate. Results: The prevalence of malnutrition was 5.8%. Although Klidjian showed the highest sensitivity (79%, 95% CI 62%–90%), 6 out of 29 malnourished patients were falsely identified as well-nourished (false positive rate 21%, 95% CI 9%–38%). In contrast, this algorithm showed the lowest positive predictive value (8%, 95% CI 5%–13%). Matos presented the highest positive predictive value; the post-test probability increased to 13% (95% CI 8%–20%). The 1-minus negative predictive value ranged between 3% and 5% for all algorithms. Conclusions: None of the algorithms derived from handgrip strength measurements was found to have a diagnostic accuracy good enough to introduce handgrip strength as a systematic institutional screening tool to detect malnutrition in individual adult preoperative elective outpatients. [Copyright &y& Elsevier]

Abstract: Esophagectomy with gastric tube reconstruction results in a variety of postoperative nutrition-related complaints that can impair nutritional intake and nutritional status. The aim of this study was to determine to what extent patients reached the recommended intake of various nutrients at 6 and 12 months after esophagectomy. It was also analyzed whether a suboptimal intake could be explained by the most clinically significant nutrition-related complaints after esophagectomy. In a prospective cohort study (2002 to 2006), the nutrient intake of 96 patients, recorded in preprinted nutritional diaries, was compared with the recommended energy intake in The Netherlands and Recommended Dietary Allowance of protein and micronutrients. Energy and protein intake remained below recommendations in 24% and 7% of the patients, respectively. Less than 10% of the patients had a sufficient intake of all micronutrients. Folic acid, vitamin D, copper, calcium, and vitamin B-1 were the micronutrients most often reported to have a suboptimal intake. Multivariate logistic regression, corrected for preoperative epigastric pain and energy intake, showed that the number of nutrition-related complaints was not an independent risk factor for the presence of a suboptimal intake of nutrients (adjusted odds ratio=1.11; 95% CI: 0.94 to 1.31; P = 0.22). This study shows that the intake of micronutrients remains below recommendations in the majority of patients 12 months after esophagectomy. This problem requires special attention and care by registered dietitians. [Copyright &y& Elsevier]

Summary: Background: In the daily bedside routine of the intensive care, potentially hazardous interventions that lack evidence need critical consideration. Therefore we examined current practice and knowledge of basic principles of manual hyperinflation (MH) in intubated and mechanically ventilated patients among intensive care unit nurses in the Netherlands. Methods: A written survey method was used, questionnaires were sent to ICU nurses specialised in mechanical ventilation in 115 Dutch hospitals. The questions related to following domains: (1) demographics; (2) use of MH; (3) presumed benefits; (4) essential elements of the MH procedure; (5) equipment and safety. Results: The response rate was 77%. From responding ICUs the majority (96%) stated they performed MH; 27% as a daily routine procedure, 69% performed MH on indication only. MH was mainly performed by ICU nurses. Half of ICUs reported to have a MH guideline available. Improved oxygenation and better removal of sputum were presumed benefits of MH. While slow inspiration and rapid expiration are considered to be essential elements of MH procedures, the majority of respondents stated to use rapid inspiration and slow expiration. Conclusions: This survey indicates that MH is widely used as an important item of airway management. Importantly, there is no uniformity in the performance of the procedure. Before definitive research can be developed, standards for the MH procedure should be established. [Copyright &y& Elsevier]

Background: Since more sophisticated ventilation techniques have enabled patients to comply with the ventilator with little or no sedation, deep sedation levels can easily be avoided. However, successful ventilation techniques also expanded the treatment possibilities for more severely ill patients who require deeper sedation levels. We developed a new sedation score to improve the prevention of oversedation and to simplify scoring practice in the intensive care unit (ICU). Objective: The study’s objective was to establish the validity and reliability of a new sedation score (Sedic score) for critically ill, sedated adult patients. Methods: We prospectively evaluated the reliability and validity of the Sedic score. The study took place in a 30-bed ICU in a university teaching hospital. Forty-six consecutive mechanically ventilated and sedated ICU patients were included. The constructed scale consists of five levels of stimuli and five levels of responses. Sedation levels are defined by the sum of stimulus and response. The reliability of the Sedic score was assessed by simultaneous measurement by the research nurse and attending nurse (n = 70). Validity was expressed as (1) the hierarchic relation between stimulus and response (n = 443), (2) the prediction of wake-up time by the Sedic score (n = 46), and (3) the association between the Sedic score and the Ramsay scale (n = 88). Results: The method showed excellent reliability. Validity: Weighted kappa between stimulus and response was .82. Multivariate analysis: (recovery time as independent variable) regression line (Y = −2.53 + 2.16 * β; P < .001) (r2 = 42%). Correlation between the Sedic scores and the Ramsay scores was rs .74 (P = .01). Sixty-seven percent of the patients with a maximum Ramsay score of 6 had scores ranging between 6 and 10 on the Sedic scale, indicating that the Ramsay scale has a serious ceiling effect. Conclusion: The Sedic score demonstrates sufficient reliability and validity, and correlates well with wake-up time. It allows for frequent use by nurses to avoid oversedation in patients. [Copyright &y& Elsevier]

Abstract: Aim: Mild hypothermia is increasingly applied in the intensive care unit. Knowledge on the effects of hypothermia on respiratory parameters during mechanical ventilation is limited. In this retrospective study, we describe the effect of hypothermia on gas exchange in patients cooled for 24h after a cardiac arrest. Methods: Respiratory parameters were derived from electronic patient files from 65 patients at the start and end of the hypothermic phase and at every centigrade increase in body temperature until normo-temperature, including tidal volume, positive end expiratory pressure (PEEP), plateau pressure, respiratory rate, exhaled CO2 concentrations (etCO2) and FIO2. Static compliance was calculated as V T/P plateau −PEEP. Dead space ventilation was calculated as (PaCO2 −etCO2)/PaCO2. Results: During hypothermia, PaCO2 decreased, at unchanged PaCO2–etCO2 gap and minute ventilation. During rewarming, PaCO2 did not change, while etCO2 increased at unchanged minute ventilation. Dead space ventilation did not change during hypothermia, but lowered during rewarming. During hypothermia, PaO2/FIO2 ratio increased at unchanged PEEP levels. Respiratory static compliance did not change during hypothermia, nor during rewarming. Conclusion: Hypothermia possibly improves oxygenation and ventilation in mechanically ventilated patients. Results may accord with the hypothesis that reducing metabolism with applied hypothermia may be beneficial in patients with acute lung injury, in whom low minute ventilation results in severe hypercapnia. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Treatment with hypothermia has been shown to improve outcome after cardiac arrest (CA). Current consensus is to rewarm at 0.25–0.5°C/h and avoid fever. The aim of this study was to investigate whether active rewarming, the rate of rewarming or development of fever after treatment with hypothermia after CA was correlated with poor outcome. Methods: This retrospective cohort study included adult patients treated with hypothermia after CA and admitted to the intensive care unit between January 2006 and January 2009. The average rewarming rate from end of hypothermia treatment (passive rewarming) or start active rewarming until 36°C was dichotomized in a high (≥0.5°C/h) or normal rate (<0.5°C/h). Fever was defined as >38°C within 72h after admission. Poor outcome was defined as death, vegetative state, or severe disability after 6months. Results: From 128 included patients, 56% had a poor outcome. Actively rewarmed patients (38%) had a higher risk for poor outcome, OR 2.14 (1.01–4.57), p <0.05. However, this effect disappeared after adjustment for the confounders age and initial rhythm, OR 1.51 (0.64–3.58). A poor outcome was found in 15/21 patients (71%) with a high rewarming rate, compared to 54/103 patients (52%) with a normal rewarming rate, OR 2.61 (0.88–7.73), p =0.08. Fever was not associated with outcome, OR 0.64 (0.31–1.30), p =0.22. Conclusions: This study showed that patients who needed active rewarming after therapeutic hypothermia after CA did not have a higher risk for a poor outcome. In addition, neither speed of rewarming, nor development of fever had an effect on outcome. [Copyright &y& Elsevier]

Abstract: Background: Preoperative screening for malnutrition has become mandatory in The Netherlands. A sensitive method to diagnose malnutrition would save time and improve effectiveness. Methods: A prospective cross-sectional study of 488 adult elective preoperative outpatients was performed. The accuracy of self-reported height and weight was compared with measured data and 3 commonly used malnutrition screening tools. Interobserver agreement was calculated by the intraclass correlation coefficient, studied in Bland and Altman plots, and analyzed by using Cohen''s κ statistic. Accuracy was expressed in sensitivity, specificity, and false-negative rates. Results: Differences between self-reported and measured data were significant, but clinically irrelevant, because only 1 patient was falsely identified as well nourished. Intraclass correlation coefficient for height, weight, and body mass index was high (.97–.99). Bland–Altman plots showed that the mean ± standard deviation differences and 95% limits of agreement between both methods were as follows: height, .0096 m (±.0262, −.0417 to +.0609 m); weight, −1.28 kg (±2.29, −5.76 to +3.20 kg); body mass index, −.72 kg/m2 (±1.11, −2.92 to +1.46 kg/m2). The κ coefficient was .84 (95% confidence interval, .75–.94). Sensitivity was .97 and specificity was .98. Sensitivity and false-negative rates of self-reported data were better overall compared with the screening tools. Conclusions: Self-reported data provide highly sensitive information to diagnose malnutrition in preoperative outpatients. [Copyright &y& Elsevier]