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Early high protein provision and mortality in ICU patients including those receiving continuous renal replacement therapy

BACKGROUND: Findings on the association between early high protein provision and mortality in ICU patients are inconsistent. The relation between early high protein provision and mortality in patients receiving CRRT remains unclear. The aim was to study the association between early high protein provision and hospital and ICU mortality and consistency in subgroups.METHODS: A retrospective cohort study was conducted in 2618 ICU patients with a feeding tube and mechanically ventilated ≥48 h (2003-2016). The association between early high protein provision (≥1.2 g/kg/day at day 4 vs. <1.2 g/kg/day) and hospital and ICU mortality was assessed for the total group, for patients receiving CRRT, and for non-septic and septic patients, by Cox proportional hazards analysis. Adjustments were made for APACHE II score, energy provision, BMI, and age.RESULTS: Mean protein provision at day 4 was 0.96 ± 0.48 g/kg/day. A significant association between early high protein provision and lower hospital mortality was found in the total group (HR 0.48, 95% CI 0.39-0.60, p = <0.001), CRRT-receiving patients (HR 0.62, 95% CI 0.39-0.99, p = 0.045) and non-septic patients (HR 0.56, 95% CI 0.44-0.71, p = <0.001). However, no association was found in septic patients (HR 0.71, 95% CI 0.39-1.29, p = 0.264). These associations were very similar for ICU mortality. In a sensitivity analysis for patients receiving a relative energy provision >50%, results remained robust in all groups except for patients receiving CRRT.CONCLUSIONS: Early high protein provision is associated with lower hospital and ICU mortality in ICU patients, including CRRT-receiving patients. There was no association for septic patients.

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Early high protein provision and mortality in ICU patients including those receiving continuous renal replacement therapy

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Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study

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Acceleration of direct identification of S.aureus versus Coagulase Negative Staphylococci from blood culture material: a comparison of six bacterial DNA extraction methods

To accelerate differentiation between Staphylococcus aureus and Coagulase Negative Staphylococci (CNS), this study aimed to compare six different DNA extraction methods from 2 commonly used blood culture materials, i.e. BACTEC and Bact/ALERT. Furthermore, we analyzed the effect of reduced blood culture times for detection of Staphylococci directly from blood culture material. A real-time PCR duplex assay was used to compare 6 different DNA isolation protocols on two different blood culture systems. Negative blood culture material was spiked with MRSA. Bacterial DNA was isolated with: automated extractor EasyMAG (3 protocols), automated extractor MagNA Pure LC (LC Microbiology Kit MGrade), a manual kit MolYsis Plus, and a combination between MolYsis Plus and the EasyMAG. The most optimal isolation method was used to evaluate reduced bacterial culture times. Bacterial DNA isolation with the MolYsis Plus kit in combination with the specific B protocol on the EasyMAG resulted in the most sensitive detection of S.aureus, with a detection limit of 10 CFU/ml, in Bact/ALERT material, whereas using BACTEC resulted in a detection limit of 100 CFU/ml. An initial S.aureus load of 1 CFU/ml blood can be detected after 5 hours of culture in Bact/ALERT3D by combining the sensitive isolation method and the tuf LightCycler assay.

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Acceleration of direct identification of S.aureus versus Coagulase Negative Staphylococci from blood culture material: a comparison of six bacterial DNA extraction methods

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Differences in Documented and Actual Medication Administration Time in the Emergency Department: A Prospective, Observational, Time-Motion Study

Introduction: Retrospective studies suggest that a rapid initiation of treatment results in a better prognosis for patients in the emergency department. There could be a difference between the actual medication administration time and the documented time in the electronic health record. In this study, the difference between the observed medication administration time and documentation time was investigated. Patient and nurse characteristics were also tested for associations with observed time differences. Methods: In this prospective study, emergency nurses were followed by observers for a total of 3 months. Patient inclusion was divided over 2 time periods. The difference in the observed medication administration time and the corresponding electronic health record documentation time was measured. The association between patient/nurse characteristics and the difference in medication administration and documentation time was tested with a Spearman correlation or biserial correlation test. Results: In 34 observed patients, the median difference in administration and documentation time was 6.0 minutes (interquartile range 2.0-16.0). In 9 (26.5%) patients, the actual time of medication administration differed more than 15 minutes with the electronic health record documentation time. High temperature, lower saturation, oxygen-dependency, and high Modified Early Warning Score were all correlated with an increasing difference between administration and documentation times. Discussion: A difference between administration and documentation times of medication in the emergency department may be common, especially for more acute patients. This could bias, in part, previously reported time-to-treatment measurements from retrospective research designs, which should be kept in mind when outcomes of retrospective time-to-treatment studies are evaluated.

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Differences in Documented and Actual Medication Administration Time in the Emergency Department: A Prospective, Observational, Time-Motion Study

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Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

Abstract: INTRODUCTION: Early protein and energy feeding in critically ill patients is heavily debated and early protein feeding hardly studied.

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Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

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Participatory development via user-involvement - A Case Study about the development of a Web-based Patient-communication system about Methicillin-resistant Staphylococcusaureus

This paper describes the participatory development process of a web-based communication system focusing on disease management, particularly infection control of Methicillin-resistant Staphylococcus aureus (MRSA). These infections are becoming a major public health issue; they can have serious consequences such as pneumonia, sepsis or death [1]. This makes it even more important for people to be provided with up-to-date and reliable information. Users of a bilingual communication system (Dutch and German) participated in the development process via a needs assessment, the co-creation of the content and the system via usability tests, and in the summative evaluation of the usage of the system. The system enabled users to search efficiently and effectively for practical and relevant information. Moreover, we found that the participation of the intended users is a prerequisite to create a fit between the needs and expectations of the end-users, the technology and the social context of usage of technology. The summative evaluation showed that the system was frequently used (approximately 11,000 unique visitors per month). The most popular categories include ‘MRSA in general’ (20%, both languages) and ‘Acquiring MRSA’ (17% NL, 13% GER). Most users enter the site using internet search engines (Google) instead of the on-site search engine. When they are on the site, they prefer convenient searching via FAQ or related questions. Furthermore, the results showed that the participation of stakeholders is a prerequisite for a successful implementation of the system. To guide the participation of stakeholders we developed a roadmap that integrates human-centered development with business modelling activities.

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Participatory development via user-involvement - A Case Study about the development of a Web-based Patient-communication system about Methicillin-resistant Staphylococcusaureus

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Route, early or energy? … Protein improves protein balance in critically ill patients.

The critical care community still has mixed feelings when considering the optimal nutrition of intensive care unit (ICU) patients, which is understandable as randomized controlled trials have not been very helpful in improving clinical practice. There have been no randomized controlled trials (RCTs) to contribute to the discussion, especially concerning the role of enterally fed protein in optimal critical care. Recent studies on the route of feeding have shown that enteral nutrition (EN) is not necessarily superior to parenteral nutrition (PN) [1, 2]. There appears to be a strong consensus, with backup from a meta-analysis, on the preferential use of EN over PN [3]. The infection rate was especially used as an argument; however, this is not substantiated in recent trials [1, 2]. We have to consider how applicable this current knowledge is to all ICU patients. Early EN is still the preferred way of feeding [3]. Starting feeding early may improve the outcome of ICU patients. RCTs have all investigated (supplemental parenteral) energy delivery [4]. Only two trials have ‘considered’ protein: the PERMIT trial [5] (protein supplemented, equal level) and EAT-ICU trial [6] (protein supplemented, higher level). Early energy delivery should be applied cautiously since it appears to be related to worse outcome in ICU patients [7, 8, 9]. Therefore, and from the perspective of clinical practice, the Swiss Supplemental PN (SPN) trial appears to provide the most logical design [10]—start with early EN and evaluate on day 3 what the level of energy delivery is; when delivery levels are low (< 60%) start supplementation PN. In clinical practice in our ICU the enteral feeding levels are high enough to avoid PN supplementation, which therefore restricts the specific indication to use PN. The focus of this research has been caloric delivery. There are more than enough observational data to support that higher protein delivery is associated with improved outcome in ICU patients [7, 8, 9]. These observational studies clearly show the benefit of higher protein delivery. However, they are considered relatively weak evidence since illness is considered a confounding factor in the relationship between delivery and outcome for which we cannot completely adjust. Randomized trials have not been conducted, although two trials with randomized high(er) amino acid infusion are available and somewhat contradicting [11, 12]. As with the studies on caloric delivery, the studies on protein have been hampered by insufficient knowledge on energy and protein metabolism under these (patho)physiological circumstances in the ICU patient [7, 8, 9]. Therefore, mechanistic studies on the protein physiology in ICU patients is an essential and current development. The Swedish group of Wernerman and Rooyackers has provided crucial information on the topic. They showed that it was possible to change protein balance during the early phase of admission to the ICU from negative to positive by a short-term (3-h) high-level (1 g/kg/day) amino acid (AA) infusion [13]. This observation was very important to help understand the physiology since it showed that, under these circumstances of critical illness, some basic principles of nutrition still perform well. In the December 2017 issue of Critical Care, Sundstrom et al. showed that the effect of supplemental AA infusion at 3 h is still present at 24 h [14]. Why is this so important to know? We know from extensive studies in sports and the elderly that protein synthesis can be stimulated by bolus protein feeding; however, we know relatively little about the effects of continuous (low dose per time unit) feeding. While the absolute levels of protein balance still have to be considered with caution (e.g., choice of tracer), and we are not completely sure where the protein is going, we now know this positive effect on protein balance is lasting. The next challenge is to reconnect this physiological information with the outcome of ICU patients. We have shown that muscle (protein) mass at admission to the ICU is relevant for the outcome of ICU patients [15]. We do not know if we can change muscle mass and outcome of ICU patients with protein nutrition. The study by Sundstrom et al. [14] is very promising for protein balance, but will that be enough to change outcome? And, if so, is that true for all patients—does one size fit all? The ICU patient group is heterogeneous. Earlier, we found high protein delivery to be associated with lower mortality, except for sepsis patients and patients with early caloric overfeeding [7]. The EAT-ICU trial did not find an effect of early goal-directed feeding on physical component score at 6 months or on mortality [6]. Goal-directed feeding included feeding energy based on indirect calorimetry and protein up to 1.5 g/kg/day from day 1. Feeding calories up to the measured caloric target from day 1 may be equal to caloric overfeeding [7]. The 47% of patients with sepsis in the EAT-ICU trial might also not benefit from the higher protein feeding [7]. Therefore, the effects of protein and energy cannot be assessed individually from this trial. Ferrie et al. showed interesting differences in muscle mass and function between an AA infusion rate of 0.8 and 1.2 g/kg/day [12], but not all patients are equal—one size does not fit all! Those patients with a low protein reserve (low muscle mass) may be at highest risk in the ICU and may benefit more from intervention with early protein nutrition. We have to await further studies, including randomized studies and post-hoc observational studies, to further develop this area of interest. The studies trying to understand the mechanism behind the physiological effect are important as well; we might come nearer to the truth of what works and what does not work in ICU nutrition.

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Route, early or energy? … Protein improves protein balance in critically ill patients.

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Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old

BACKGROUND: Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear. OBJECTIVE: To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function. DESIGN: Prospective cohort study. SETTING: 241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019. SUBJECTS: Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2. METHODS: Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected. RESULTS: Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P 4): HR, 1.34 (95% CI, 1.18-1.51, P

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Sepsis at ICU admission does not decrease 30-day survival in very old patients

BACKGROUND: The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival.RESULTS: This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81-86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger, had a higher SOFA score (9 vs. 7, p < 0.0001), required more vasoactive drugs [82.2% vs. 55.1%, p < 0.0001] and renal replacement therapies [17.4% vs. 9.9%; p < 0.0001], and had more life-sustaining treatment limitations [37.3% vs. 32.1%; p = 0.02]. Frailty was similar in both groups. Unadjusted 30-day survival was not significantly different between the two groups. After adjustment for age, gender, frailty, and SOFA score, sepsis had no impact on 30-day survival [HR 0.99 (95% CI 0.86-1.15), p = 0.917]. Inverse-probability weight (IPW)-adjusted survival curves for the first 30 days after ICU admission were similar for acute septic and non-septic patients [HR: 1.00 (95% CI 0.87-1.17), p = 0.95]. A matched-pair analysis in which patients with sepsis were matched with two control patients of the same gender with the same age, SOFA score, and level of frailty was also performed. A Cox proportional hazard regression model stratified on the matched pairs showed that 30-day survival was similar in both groups [57.2% (95% CI 52.7-60.7) vs. 57.1% (95% CI 53.7-60.1), p = 0.85].CONCLUSIONS: After adjusting for organ dysfunction, sepsis at admission was not independently associated with decreased 30-day survival in this multinational study of 3869 VIPs. Age, frailty, and SOFA score were independently associated with survival.

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Early high protein provision and mortality in ICU patients including those receiving continuous renal replacement therapy

Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study

Acceleration of direct identification of S.aureus versus Coagulase Negative Staphylococci from blood culture material: a comparison of six bacterial DNA extraction methods

Differences in Documented and Actual Medication Administration Time in the Emergency Department: A Prospective, Observational, Time-Motion Study

Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

Participatory development via user-involvement - A Case Study about the development of a Web-based Patient-communication system about Methicillin-resistant Staphylococcusaureus

Route, early or energy? … Protein improves protein balance in critically ill patients.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old

Sepsis at ICU admission does not decrease 30-day survival in very old patients

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Early high protein provision and mortality in ICU patients including those receiving continuous renal replacement therapy

Protein Intake, Nutritional Status and Outcomes in ICU Survivors: A Single Center Cohort Study

Acceleration of direct identification of S.aureus versus Coagulase Negative Staphylococci from blood culture material: a comparison of six bacterial DNA extraction methods

Differences in Documented and Actual Medication Administration Time in the Emergency Department: A Prospective, Observational, Time-Motion Study

Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

Participatory development via user-involvement - A Case Study about the development of a Web-based Patient-communication system about Methicillin-resistant Staphylococcusaureus

Route, early or energy? … Protein improves protein balance in critically ill patients.

Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old

Sepsis at ICU admission does not decrease 30-day survival in very old patients