Introduction: Positive fluid status has been associated with a worse prognosis in intensive care unit (ICU) patients. Given the potential for errors in the calculation of fluid balance totals and the problem of accounting for indiscernible fluid losses, measurement of body weight change is an alternative non-invasive method commonly used for estimating body fluid status. The objective of the study is to compare the measurements of fluid balance and body weight changes over time and to assess their association with ICU mortality. Methods: This prospective observational study was conducted in the 34-bed multidisciplinary ICU of a tertiary teaching hospital in southern Brazil. Adult patients were eligible if their expected length of stay was more than 48 hours, and if they were not receiving an oral diet. Clinical demographic data, daily and cumulative fluid balance with and without indiscernible water loss, and daily and total body weight changes were recorded. Agreement between daily fluid balance and body weight change, and between cumulative fluid balance and total body weight change were calculated. Results: Cumulative fluid balance and total body weight change differed significantly among survivors and non survivors respectively, +2.53L versus +5.6L (p= 0.012) and -3.05kg vs -1.1kg (p= 0.008). The average daily difference between measured fluid balance and body weight was +0.864 L/kg with a wide interval: -3.156 to +4.885 L/kg, which remained so even after adjustment for indiscernible losses (mean bias: +0.288; limits of agreement between -3.876 and +4.452 L/kg). Areas under ROC curve for cumulative fluid balance, cumulative fluid balance with indiscernible losses and total body weight change were, respectively, 0.65, 0.56 and 0.65 (p= 0.14). Conclusion: The results indicated the absence of correspondence between fluid balance and body weight change, with a more significant discrepancy between cumulative fluid balance and total body weight change. Both fluid balance and body weight changes were significantly different among survivors and non-survivors, but neither measurement discriminated ICU mortality.
Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.
Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb<7 g/dl).
In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.