scholarly journals The contribution of plasma urea to total osmolality during iatrogenic fluid reduction in critically ill patients

Function ◽  
2021 ◽  
Author(s):  
Sandra Nihlén ◽  
Robert Frithiof ◽  
Jens Titze ◽  
Rafael Kawati ◽  
Johan Rasmusson ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Body Fluid ◽  
Plasma Osmolality ◽  
Body Water ◽  
Fluid Volume ◽  
Volume Reduction ◽  
Icu Patients ◽  
Nitrogen Intake ◽  
Body Fluid Volume

Abstract Hyperosmolality is common in critically ill patients during body fluid volume reduction. It is unknown whether this is only a result of decreased total body water, or an active osmole-producing mechanism similar to that in aestivating animals where muscle degradation increases urea levels to preserve water. We hypothesized that fluid volume reduction in critically ill patients contributes to a shift from ionic to organic osmolytes similar to mechanisms of aestivation. We performed a post-hoc analysis on data from a multicenter observational study in adult ICU patients in the post-resuscitative phase. Fluid, electrolyte, energy and nitrogen intake, fluid loss, estimated glomerular filtration rate (eGFR) and estimated plasma osmolality (eOSM) were registered. Contributions of osmolytes Na+, K+, urea and glucose to eOSM expressed as proportions of eOSM were calculated. 241 patients were included. eOSM increased (median change 7.4 mOsm/kg (IQR −1.9–18) during the study. The of sodium's and potassium's proportions of eOSM decreased (P < 0.05 and P < 0.01 respectively), whereas the urea's proportion increased (P < 0.001). Urea's proportion of eOSM was higher in patients with negative vs. positive fluid balance. The urea's proportion of eOSM increased with eOSM (r = 0.63; adjusted for eGFR r = 0.80), but not nitrogen intake. In patients without furosemide and/or renal replacement therapy (n = 17), urea's proportion of eOSM and eOSM correlated strongly (r = 0.92). Urea's proportion of eOsm was higher in patients not surviving to 90 days. In stabilized ICU patients the contribution of urea to plasma osmolality increased during body water volume reduction, statistically independently of nitrogen administration and eGFR. The shift from ionic osmolytes to urea during body fluid volume reduction is similar to that seen in aestivating animals. ClinicalTrials.org Identifier: NCT03972475

Effects of hyperosmolality and diuretics on heat-induced limb vasodilation in baboons

1990 ◽  
Vol 258 (2) ◽  
pp. R309-R317 ◽  
Author(s):  
D. W. Proppe
Keyword(s):  
Blood Flow ◽  
Body Fluid ◽  
Extracellular Fluid ◽  
Plasma Osmolality ◽  
External Iliac Artery ◽  
Sodium Concentration ◽  
Fluid Volume ◽  
Extracellular Fluid Volume ◽  
Acute Elevation ◽  
Body Fluid Volume

Dehydration attenuates the increase in limb skin blood flow elicited by environmental heating (EH). This study sought to determine which of the two primary effects of dehydration, increased body fluid osmolality or decreased body fluid volume, was primarily responsible for this cutaneous vasoconstrictor bias in baboons. Unanesthetized chronically instrumented baboons were exposed to EH while in euhydrated state, after 65-69 h of water deprivation (dehydration), after infusion of a small volume of hypertonic (20%) saline to raise plasma osmolality and sodium concentration to dehydration levels, and after injections of the diuretic furosemide over a 64-h period to produce an isosmotic fall in extracellular fluid volume. EH consisted of an acute elevation of ambient temperature to 39.5-42.0 degrees C until internal temperature reached 39.5-39.8 degrees C. The normal increases in external iliac artery blood flow and iliac vascular conductance during EH were unchanged by hyperosmolality but were attenuated by 39 and 31%, respectively, after furosemide treatment and by 42 and 46%, respectively, during dehydration. Thus the fall in extracellular fluid volume is the component of dehydration that attenuates the increase in hindlimb blood flow during EH in the same way as dehydration itself.

scholarly journals Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study (Preprint)

2019 ◽  
Author(s):  
Dong Chang ◽  
Jennifer Parrish ◽  
Nader Kamangar ◽  
Janice Liebler ◽  
May Lee ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Decision Makers ◽  
Care Planning ◽  
Improvement Strategy ◽  
Icu Patients ◽  
Family Meetings ◽  
Planning Approach ◽  
Icu Physicians

BACKGROUND Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care. OBJECTIVE The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality. METHODS This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization. RESULTS The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020. CONCLUSIONS The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16301

scholarly journals Low albumin levels are associated with poorer outcomes in a case series of COVID-19 patients in Spain: a retrospective cohort study

2020 ◽  
Author(s):  
Roberto de la Rica ◽  
Marcio Borges ◽  
María Aranda ◽  
Alberto del Castillo ◽  
Antonia Socias ◽  
...  
Keyword(s):  
Disease Severity ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Case Series ◽  
Hospitalized Patients ◽  
University Hospital ◽  
Limited Information ◽  
Icu Patients ◽  
Epidemiological Features ◽  
Initial Symptoms

ABSTRACTOBJECTIVETo describe the clinical characteristics and epidemiological features of severe (non-ICU) and critically patients (ICU) with COVID-19 at triage, prior hospitalization, in one of the main hospitals in The Balearic Islands health care system.DESIGNRetrospective observational studySETTINGSon Llatzer University Hospital in Palma de Mallorca (Spain)PARTICIPANTSAmong a cohort of 52 hospitalized patients as of 31 March 2020, 48 with complete demographic information and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive test, were analyzed. Data were collected between March 15th, 2020, and March 31th 2020, inclusive of these dates.MAIN OUTCOMESClinical, vital signs and routine laboratory outcomes at the time of hospitalization, including symptoms reported prior to hospitalization. Demographics and baseline comorbidities were also collected. Mortality was reported at the end of the study.RESULTS48 patients (27 non-ICU and 21 ICU) resident in Mallorca, Spain (mean age, 66 years, [range, 33-88 years]; 67% males) with positive SARS-CoV-2 infection were analyzed. There were no differences in age or sex among groups (p >.05). Initial symptoms included fever (100%), coughing (85%), dyspnea (76%), diarrhea (42%) and asthenia (21%). The majority of patients in this case series were hospitalized because of low SpO2 (SpO2 below 90%) and presentation of bilateral pneumonia (94%) at triage. ICU patients had a higher prevalence of dyspnea compared to non-ICU patients (95% vs 61%, p = .022). Acute respiratory syndrome (ARDS) was presented in 100% of the ICU-patients. All the patients included in the study required oxygen therapy. ICU-patients had lymphopenia as well as hypoalbuminemia. Inflammatory markers such as lactate dehydrogenase (LDH), C-reactive protein (CRP), and procalcitonin were significantly higher in ICU patients compared to non-ICU (p < .001).Lower albumin levels were associated with poor prognosis measured as longer hospital length (r= −0.472, p <.001) and mortality (r= −0.424, p=.003). Interestingly we also found, that MCV was lower among of those patients who died (p=.0002). As of April 28, 2020, 10 patients (8 ICU and 2 non-ICU) had died (21% mortality) and while 100% of the non-ICU patients had been discharged, 33% of ICU patients still remained hospitalized (5 in ICU and 2 had been transferred to ward).CONCLUSIONCritically ill patients with COVID-19 present lymphopenia, hypoalbuminemia as well high levels of inflammation. Lower levels of albumin were associated with poorer outcomes in COVID-19 patients. Albumin might be of importance because of its association with disease severity in patients infected with SARS-CoV-2.WHAT IS ALREADY KNOWN IN THIS TOPICSpain has been hit particularly hard by the pandemic. By the time that this manuscript was written more than 25.000 deaths related to COVID-19 have been confirmed. There is limited information available describing the clinical and epidemiological features of Spanish patients requiring hospitalization for COVID-19. Also, it is important to know the characteristics of the hospitalized patients who become critically illWHAT THIS STUDY ADDSThis small case series provides the first steps towards a comprehensive clinical characterization of severe and critical COVID-19 adult patients in Spain. The overall mortality in our patients was 21%. To our knowledge this is the first report with reporting these features in Spain. At triage the majority of patients had lower SpO2 (<90%) and bilateral pneumonia. The most common comorbidities were hypertension (70%), dyslipidemia (62%) and cardiovascular disease (30%). Critically ill patients present hypoalbuminemia and lymphopenia, as well as higher levels of inflammation. Albumin might be of importance because of its association with disease severity and mortality in patients infected with SARS-CoV-2.

scholarly journals A Possible Physiological Role of Atrial Natriuretic Peptide in Body Fluid Volume Regulation

1988 ◽  
Vol 13 ◽  
pp. S62-S68
Author(s):  
Yasunobu Hirata ◽  
Masao Ishii ◽  
Kazushige Fukui ◽  
Hiroshi Hayakawa ◽  
Shin-ichiro Namba ◽  
...  
Keyword(s):  
Atrial Natriuretic Peptide ◽  
Natriuretic Peptide ◽  
Volume Regulation ◽  
Body Fluid ◽  
Physiological Role ◽  
Fluid Volume ◽  
Body Fluid Volume ◽  
Fluid Volume Regulation ◽  
Atrial Natriuretic

scholarly journals Discomforts in Critically ill Patients: Our Experience in Intensive Care Unit of a Tertiary Care Hospital in India

2021 ◽  
Author(s):  
Reetu Verma ◽  
Sasmita Panda ◽  
Rajeev Kumar Nishad
Keyword(s):  
Intensive Care ◽  
Environmental Factors ◽  
Critically Ill ◽  
Nursing Care ◽  
Critically Ill Patients ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Care Hospital ◽  
Icu Patients ◽  
Common Cause

Introduction: Patients admitted in the Intensive Care Units (ICUs) experiences various discomforts which may be recognised or unrecognised. These discomforts may arise from the environment, may be related to the ICU care and discomfort related to the health status of the patient and critical care interventions. Aim: To identify the various discomforts in ICU patients, to classify them with respective causes, identify the most common cause among them and whether ICU sedation helps in reducing discomforts. Materials and Methods: This observational study was conducted from 15th July to 15th October 2018 on 120 mixed ICU patients in a Tertiary Care Hospital in India. Patients who were admitted to ICU for more than 24 hours, aged 18 years and above, those who gave written informed consent were observed and enquired for any discomfort. Discomforts have been identified and recorded by a fulltime intensivist by direct observation, by interacting with the patients and asking the family members and others (indirect approach). Through this study discomforts of critically ill patients were broadly classified into four categories 1. Due to existing illness, 2. Due to ICU interventions, 3. Due to improper nursing care and 4. Due to environmental factors. Results: Out of 120 patients studied, 84 patients (70%) reported some kind of discomfort during their ICU stay. Existing illness was the most common cause of discomfort, 80 patients (66.6%) suffered due to it. ICU interventions was the second most common cause, 71 patients (59.1%) had discomfort due to interventions. Thirty five patients (29.1%) suffered due to improper nursing care and 25 patients (20.8%) suffered due to the environmental factors. In this study, it was observed that sedation reduces all kind of discomforts. conclusion: In this study 70% of patients, who were admitted to ICU due to various illness reported some kind of discomfort. The most common cause of ICU discomforts was existing illness followed by ICU interventions. In this study it was observed that sedation reduces all kind of discomforts. Sedated patients tolerate the endotracheal tube better and they had less environmental and procedure related discomforts. With the present study observation it can be suggested that ICU charts of nurses and doctors can carry a separate column for mentioning discomforts in different duty shifts. However, with the use of appropriate analgesia and sedation discomfort can be reduced.

scholarly journals Apparent paradox of neurohumoral axis inhibition after body fluid volume depletion in patients with chronic congestive heart failure and water retention.

Heart ◽  
1994 ◽  
Vol 72 (6) ◽  
pp. 534-539 ◽  
Author(s):  
M D Guazzi ◽  
P Agostoni ◽  
B Perego ◽  
G Lauri ◽  
A Salvioni ◽  
...  
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Body Fluid ◽  
Water Retention ◽  
Fluid Volume ◽  
Chronic Congestive Heart Failure ◽  
Volume Depletion ◽  
Apparent Paradox ◽  
Body Fluid Volume

Abstract 13704: Simulation-based Uptraining Improves Provider Comfort in the Management of Critically Ill Patients With Covid-19

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
James M Horowitz ◽  
Eugene Yuriditsky ◽  
Sunil Nair ◽  
Brian S Kaufman
Keyword(s):  
Critically Ill ◽  
Nurse Practitioners ◽  
Critically Ill Patients ◽  
Simulation Training ◽  
Icu Patients ◽  
Large Numbers ◽  
Simulation Based ◽  
Critical Care Ultrasound ◽  
Simulation Session ◽  
Icu Physicians

Introduction: The COVID-19 surge at our institution required deployment of large numbers of non-intensive care unit (ICU) physicians and advanced practice providers to assist in the management of the critically ill. A 3-hour “uptraining” simulation session was offered to these providers that focused on various aspects of ICU care. Hypothesis: We hypothesized that following a 3-hour simulation session, providers would feel more comfortable in managing critically-ill patients with COVID-19. Methods: One hundred and seventy-five providers underwent a 3-hour simulation-based session focused on management of shock, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of ICU care following return to their usual work environments. Results: One hundred and eight providers of 175 (62%) completed the surveys. Cardiology fellows and faculty accounted for 36% of the responders, acute care nurse practitioners (NPs) accounted for 16%, while other NPs, residents, and fellows accounted for the remainder. Prior to simulation training, 31% regularly managed patients in the ICU and 28% occasionally managed ICU patients. Following training, 71% of participants were deployed to a COVID-19 ICU as part of their workflow. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Ninety-four participants (91%) felt training impacted their care of critically ill patients with COVID-19. Table 1 is a display of specific ICU skillsets taught in the session and if the participants felt better equipped to utilize what was covered post deployment. Conclusions: Simulation-based training improved provider comfort in the management of critically ill patients with COVID-19. Table 1: Participants response to “if they felt better equipped to utilize ICU skills following simulation training”

scholarly journals Colistin-Resistant Acinetobacter Baumannii Bacteremia: A Serious Threat for Critically Ill Patients

2020 ◽  
Vol 8 (2) ◽  
pp. 287 ◽  
Author(s):  
Georgios Papathanakos ◽  
Ioannis Andrianopoulos ◽  
Athanasios Papathanasiou ◽  
Efthalia Priavali ◽  
Despoina Koulenti ◽  
...  
Keyword(s):  
Septic Shock ◽  
Acinetobacter Baumannii ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Clinical Problem ◽  
Hospital Infections ◽  
Colistin Resistance ◽  
Icu Patients ◽  
Icu Admission ◽  
Comorbidity Index

The prevalence of acinetobacter baumannii (AB) as a cause of hospital infections has been rising. Unfortunately, emerging colistin resistance limits therapeutic options and affects the outcome. The aim of the study was to confirm our clinically-driven hypothesis that intensive care unit (ICU) patients with AB resistant-to-colistin (ABCoR) bloodstream infection (BSI) develop fulminant septic shock and die. We conducted a 28-month retrospective observational study including all patients developing AB infection on ICU admission or during ICU stay. From 622 screened patients, 31 patients with BSI sepsis were identified. Thirteen (41.9%) patients had ABCoR BSI and 18/31 (58.1%) had colistin-susceptible (ABCoS) BSI. All ABCoR BSI patients died; of them, 69% (9/13) presented with fulminant septic shock and died within the first 3 days from its onset. ABCoR BSI patients compared to ABCoS BSI patients had higher mortality (100% vs. 50%, respectively (p = 0.001)), died sooner (p = 0.006), had lower pH (p = 0.004) and higher lactate on ICU admission (p = 0.0001), and had higher APACHE II (p = 0.01) and Charlson Comorbidity Index scores (p = 0.044). In conclusion, we documented that critically ill patients with ABCoR BSI exhibit fulminant septic shock with excessive mortality. Our results highlight the emerging clinical problem of AB colistin resistance among ICU patients.

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