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The implementation of a nutrition protocol in a surgical intensive care unit; a randomized controlled trial at a tertiary care hospital.

ABSTRACT: BACKGROUND:Malnutrition in critically ill patients is linked with significant mortality and morbidity. However, it remains controversial whether nutrition therapy protocols are effective in improving clinical outcomes. The present study aimed to evaluate the effectiveness of a surgical ICU nutrition protocol, and to compare the hospital mortality, hospital LOS, and ICU LOS of protocol and non-protocol groups. METHODS:A randomized controlled trial was conducted at the Surgical ICU, Siriraj Hospital. The nutrition administration of the control group was at the discretion of the attending physicians, whereas that of the intervention group followed the "Siriraj Surgical ICU Nutrition Protocol". Details of the demographic data, nutritional data, and clinical outcomes were collected. RESULTS:In all, 170 patients underwent randomization, with 85 individuals each in the protocol and non-protocol groups. More than 90% of the patients in both groups were at risk of malnutrition, indicated by a score of ≥ 3 on the Nutritional Risk Screening 2002 tool. The average daily calories of the 2 groups were very similar (protocol group, 775.4±342.2 kcal vs. control group, 773.0±391.9 kcal; p = 0.972). However, the median time to commence enteral nutrition was shorter for the protocol group (1.94 days) than the control group (2.25 days; p = 0.503). Enteral nutrition was provided within the first 48 hours to 53.7% of the protocol patients vs. 47.4% of the control patients (p = 0.589). In addition, a higher proportion of the protocol patients (36.5%) reached the 60% calorie-target on Day 4 after admission than that for the non-protocol group (25.9%; p = 0.136). All other clinical outcomes and nutrition-related complications were not significantly different. CONCLUSIONS:The implementation of the nutrition protocol did not improve the feeding effectiveness or clinical outcomes as compared to usual nutrition management practices of the Surgical ICU.

SUBMITTER: Chinda P

PROVIDER: S-EPMC7162472 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Antibiotic resistance is on the rise. A contributing factor to antibiotic resistance is the misuse of antibiotics in hospitals. The current use of antibiotics in ICUs in Malawi is not well documented and there are no national guidelines for the use of antibiotics in ICUs. The aim of the study was to describe the use of antibiotics in a Malawian ICU. METHODS:A retrospective review of medical records of all admissions to the main ICU in Queen Elizabeth Central Hospital in Blantyre, Malawi, between January 2017 and April 2019. Data were extracted from the ICU patient register on clinical parameters on admission, diagnoses, demographics and antibiotics both prescribed and given for all patients admitted to the ICU. Usage of antibiotics in the ICU and bacterial culture results from samples taken in the ICU and in the peri-ICU period, (from 5 days before ICU admission to 5 days after ICU discharge), were described. RESULTS:Six hundred-and-forty patients had data available on prescribed and received medications and were included in the analyses. Of these, 577 (90.2%) were prescribed, and 522 (81.6%) received an antibiotic in ICU. The most commonly used antibiotics were ceftriaxone, given to 470 (73.4%) of the patients and metronidazole to 354 (55.3%). Three-hundred-and-thirty-three (52.0%) of the patients received more than one type of antibiotic concurrently - ceftriaxone and metronidazole was the most common combination, given to 317 patients. Forty five patients (7.0%) were given different antibiotics sequentially. One-hundred-and-thirty-seven patients (21.4%) had a blood culture done in the peri-ICU period, of which 70 (11.0% of the patients) were done in the ICU. Twenty-five (18.3%) of the peri-ICU cultures were positive and eleven different types of bacteria were grown in the cultures, of which 17.2% were sensitive to ceftriaxone. CONCLUSION:We have found a substantial usage of antibiotics in an ICU in Malawi. Ceftriaxone, the last-line antibiotic in the national treatment guidelines, is commonly used, and bacteria appear to show high levels of resistance to it, although blood culture testing is infrequently used. Structured antibiotic stewardship programs may be useful in all ICUs.

Project description:OBJECTIVES:Unplanned readmissions to the intensive care unit (ICU) are highly undesirable, increasing variance in care, making resource planning difficult and potentially increasing length of stay and mortality in some settings. Identifying patients who are likely to suffer unplanned ICU readmission could reduce the frequency of this adverse event. SETTING:A single academic, tertiary care hospital in the UK. PARTICIPANTS:A set of 3326 ICU episodes collected between October 2014 and August 2016. All records were of patients who visited an ICU at some point during their stay. We excluded patients who were ?16 years of age; visited ICUs other than the general and neurosciences ICU; were missing crucial electronic patient record measurements; or had indeterminate ICU discharge outcomes or very early or extremely late discharge times. After exclusion, 2018 outcome-labelled episodes remained. PRIMARY AND SECONDARY OUTCOME MEASURES:Area under the receiver operating characteristic curve (AUROC) for prediction of unplanned ICU readmission or in-hospital death within 48?hours of first ICU discharge. RESULTS:In 10-fold cross-validation, an ensemble predictor was trained on data from both the target hospital and the Medical Information Mart for Intensive Care (MIMIC-III) database and tested on the target hospital's data. This predictor discriminated between patients with the unplanned ICU readmission or death outcome and those without this outcome, attaining mean AUROC of 0.7095 (SE 0.0260), superior to the purpose-built Stability and Workload Index for Transfer (SWIFT) score (AUROC=0.6082, SE 0.0249; p=0.014, pairwise t-test). CONCLUSIONS:Despite the inherent difficulties, we demonstrate that a novel machine learning algorithm based on transfer learning could achieve good discrimination, over and above that of the treating clinicians or the value added by the SWIFT score. Accurate prediction of unplanned readmission could be used to target resources more efficiently.

Project description:BACKGROUND:Tetanus is a vaccine-preventable, neglected disease that is life threatening if acquired and occurs most frequently in regions where vaccination coverage is incomplete. Challenges in vaccination coverage contribute to the occurrence of non-neonatal tetanus in sub-Saharan countries, with high case fatality rates. The current WHO recommendations for the management of tetanus include close patient monitoring, administration of immune globulin, sedation, analgesia, wound hygiene and airway support [1]. In response to these recommendations, our tertiary referral hospital in Tanzania implemented a standardized clinical protocol for care of patients with tetanus in 2006 and a subsequent modification in 2012. In this study we aimed to assess the impact of the protocol on clinical care of tetanus patients and their outcomes. METHODS AND FINDINGS:We examined provision of care and outcomes among all patients admitted with non-neonatal tetanus to the ICU at Bugando Medical Centre between 2001 and 2016 in this retrospective cohort study. We compared three groups: the pre-protocol group (2001-2005), the Early protocol group (2006-2011), and the Late protocol group (2012-2016) and determined associations with mortality by univariable logistic regression. We observed a significant increase in provision of care as per protocol between the Early and Late groups. Patients in the Late group had a significantly higher utilization of mechanical ventilation (69.9% vs 22.0%, p< 0.0001), provision of surgical wound care (39.8% vs 20.3%, p = 0.011), and performance of tracheostomies (36.8% vs 6.7%, <0.0001) than patients in the Early group. Despite the increased provision of care, we found no significant decrease in overall mortality in the Early versus the Late groups (55.4% versus 40.3%, p = 0.069), or between the pre-protocol and post-protocol groups (60.7% versus 50.0%, p = 0.28). There was also no difference in 7-day ICU mortality (30.1% versus 27.8%, p = 0.70). Analysis of the causes of death revealed a decrease in deaths related to airway compromise (30.0% to 1.8%, p<0.001) but an increase in deaths due to presumed sepsis (15.0% to 44.6%, p = 0.018). CONCLUSION:The overall mortality in patients suffering non-neonatal tetanus is high (>40%). Institution of a standardized tetanus management protocol, in accordance with WHO recommendations, decreased immediate mortality related to primary causes of death after tetanus. However, this was offset by an increase in death due to later ICU complications such as sepsis. Our results illustrate the complexity in achieving mortality reduction even in illnesses thought to require few critical care interventions. Improving basic ICU care and strengthening vaccination programs to prevent tetanus altogether are essential components of efforts to decrease the mortality caused by this lethal, neglected disease.

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The implementation of a nutrition protocol in a surgical intensive care unit; a randomized controlled trial at a tertiary care hospital.

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