10 research outputs found
Pragmatic approach to nutrition in the ICU: Expert opinion regarding which calorie protein target
No full textBACKGROUND & AIMS:Since the publications of the ESPEN guidelines on enteral and parenteral nutrition in ICU, numerous studies have added information to assist the nutritional management of critically ill patients regarding the recognition of the right population to feed, the energy-protein targeting, the route and the timing to start.
METHODS: We reviewed and discussed the literature related to nutrition in the ICU from 2006 until October 2013.
RESULTS: To identify safe, minimal and maximal amounts for the different nutrients and at the different stages of the acute illness is necessary. These amounts might be specific for different phases in the time course of the patient's illness. The best approach is to target the energy goal defined by indirect calorimetry. High protein intake (1.5 g/kg/d) is recommended during the early phase of the ICU stay, regardless of the simultaneous calorie intake. This recommendation can reduce catabolism. Later on, high protein intake remains recommended, likely combined with a sufficient amount of energy to avoid proteolysis.
CONCLUSIONS: Pragmatic recommendations are proposed to practically optimize nutritional therapy based on recent publications. However, on some issues, there is insufficient evidence to make expert recommendations
Free serum cortisol during the postoperative acute phase response determined by equilibrium dialysis liquid chromatography-tandem mass spectrometry
No full textIn severely ill patients low concentrations of the corticosteroid binding globulin are typically found; the aim of this study was to quantify directly free bioactive cortisol concentrations in the sera of postoperative cardiosurgical patients. Serum samples of 12 consecutive patients undergoing aortocoronary bypass surgery taken preoperatively and on the postoperative days 1 to 4 were analyzed. Total serum cortisol was quantified using liquid chromatographytandem mass spectrometry with an online sample extraction system and trideuterated cortisol as the internal standard, and free serum cortisol was measured after overnight equilibrium dialysis. Whereas on the first postoperative day, the median total serum cortisol concentration was approximately twofold increased compared to preoperative samples (preoperatively, 245 nmol/l (interquartile range (IQR) 203293 nmol/l); first postoperative day, 512 nmol/l (IQR 410611 nmol/l)), median dialyzable free cortisol concentration was almost sevenfold increased (preoperatively, 14.2 nmol/l (IQR 10.920.7 nmol/l); first postoperative day, 98.3 nmol/l (IQR 81.3134 nmol/l)). On the fourth postoperative day, median free cortisol was still significantly increased compared to baseline sampling (p < 0.05), whereas median total cortisol was not. A median of 5.7% (IQR 5.47.0%) of total cortisol was found as free cortisol on the preoperative day, 21.2% (IQR 18.9 23.5%) on the first postoperative day and 10.5% (IQR 9.814.0%) on the fourth postoperative day. It is concluded that during the postoperative period the freeto bound ratio of cortisol is highly variable and that during the acute phase response direct quantification of free bioactive cortisol concentrations seems to be biologically more appropriate than the measurement of total cortisol concentrations
High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial
No full textIMPORTANCE: Enteral administration of immune-modulating nutrients (eg, glutamine, omega-3 fatty acids, selenium, and antioxidants) has been suggested to reduce infections and improve recovery from critical illness. However, controversy exists on the use of immune-modulating enteral nutrition, reflected by lack of consensus in guidelines.
OBJECTIVE: To determine whether high-protein enteral nutrition enriched with immune-modulating nutrients (IMHP) reduces the incidence of infections compared with standard high-protein enteral nutrition (HP) in mechanically ventilated critically ill patients.
DESIGN, SETTING, AND PARTICIPANTS: The MetaPlus study, a randomized, double-blind, multicenter trial, was conducted from February 2010 through April 2012 including a 6-month follow-up period in 14 intensive care units (ICUs) in the Netherlands, Germany, France, and Belgium. A total of 301 adult patients who were expected to be ventilated for more than 72 hours and to require enteral nutrition for more than 72 hours were randomized to the IMHP (n = 152) or HP (n = 149) group and included in an intention-to-treat analysis, performed for the total population as well as predefined medical, surgical, and trauma subpopulations.
INTERVENTIONS: High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition, initiated within 48 hours of ICU admission and continued during the ICU stay for a maximum of 28 days.
MAIN OUTCOMES AND MEASURES: The primary outcome measure was incidence of new infections according to the Centers for Disease Control and Prevention (CDC) definitions. Secondary end points included mortality, Sequential Organ Failure Assessment (SOFA) scores, mechanical ventilation duration, ICU and hospital lengths of stay, and subtypes of infections according CDC definitions.
RESULTS: There were no statistically significant differences in incidence of new infections between the groups: 53%(95% CI, 44%-61%) in the IMHP group vs 52%(95% CI, 44%-61%) in the HP group (P = .96). No statistically significant differences were observed in other end points, except for a higher 6-month mortality rate in the medical subgroup: 54%(95% CI, 40%-67%) in the IMHP group vs 35%(95% CI, 22%-49%) in the HP group (P = .04), with a hazard ratio of 1.57 (95% CI, 1.03-2.39; P = .04) for 6-month mortality adjusted for age and Acute Physiology and Chronic Health Evaluation II score comparing the groups.
CONCLUSIONS AND RELEVANCE: Among adult patients breathing with the aid of mechanical ventilation in the ICU, IMHP compared with HP did not improve infectious complications or other clinical end points and may be harmful as suggested by increased adjusted mortality at 6 months. These findings do not support the use of IMHP nutrients in these patients
Intensivmedizinische Qualitätsindikatoren für Deutschland - vierte Auflage 2022
No full textThe measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.Die Messung relevanter Qualitätsindikatoren unterstützt Initiativen zur Qualitätsverbesserung. Die Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI) hat die intensivmedizinischen Qualitätsindikatoren nun zum vierten Mal publiziert. Sie wurden nach drei Jahren überarbeitet und einige Indikatoren wurden angepasst. Andere Indikatoren erfuhren keine oder nur minimale Änderungen. Der Fokus besteht weiter auf relevanten Behandlungsprozessen wie Management von Analgesie und Sedierung, Beatmung und Weaning sowie Infektionen auf der Intensivstation. Die Gesamtzahl von zehn Indikatoren blieb bestehen. Die Entwicklung der Indikatoren erfolgte in der neuen Version nach einem anderen Prozess. Die Transparenz wurde durch Erwähnung der Einzelbeiträge der Autoren sowie auch potenzieller Interessenkonflikte erhöht. Die Anwendung der Qualitätsindikatoren im Peer-Review-Prozess der DIVI ist weiter wesentlicher Schwerpunkt. Aber auch andere Anwendungen, z.B. im Qualitätsmanagement, sind sinnvoll. Diese vierte Auflage der Qualitätsindikatoren wird noch einmal aktualisiert, um die kürzlich veröffentlichten Empfehlungen der DIVI zur Struktur der Intensivstationen zu berücksichtigen
Effective Learning Support in Higher Education: My Living Theory of student-centred learning support in National College of Ireland.
No full textThis thesis is the product of my living theory of effective learning support practices in National College of Ireland. As a journey of improvement, it describes how I came to be a learning support tutor and attempted to put in place educational practices and resources that were equally accessible, fair and supportive to all students.
This process of improvement is described using a self-study action research approach, which I used to reflect on my teaching practices. Using mixed methodology I combined my own self-reflection with the views of students, which together allowed me to identify areas where I needed to improve upon. Having then identified that I was living in a state of contradiction, I applied elements of universal design theory, inclusive teaching practices and concepts of equality, to create three principles of student-centred learning support.
Incorporating these principles into my living educational theory, I later attempted to improve my pedagogy, my resources and accessibility for all students in National College of Ireland. As a means to accomplish these goals I studied teaching and learning theories, developed a learning support manual based on national and international best practices and created a virtual learning support service.
The effectiveness of these activities were evaluated using self-reflection, surveys, interviews, peer review at conferences, as well as the quantitative analysis of student results. Through the use of these mixed methods, I make the claim that my efforts to improve my service were both qualitatively accepted by both students and my peers as well as quantitatively effective in helping to increase student performance.
In adopting paradigm relativism and mixed methodologies, this work seeks to develop a hybrid approach to practitioner research by incorporating elements of both traditional action research and self-focussed approaches.
As an insight into how student centrism can be improved upon in Higher Education, my research may have significance for other learning support tutors, directors of learning and teaching and faculty who wish to increase their own student-centred activities
Wissensstandsanalyse zu Qualität, Verbraucherschutz und Verarbeitung ökologischer Lebensmittel
No full textZielsetzung des Projektes war es, den aktuellen Stand des Wissens zur Qualität und Verarbeitung ökologischer Lebensmittel sowie zum Verbraucherschutz aufzuzeigen und zu bewerten.
Das Projektteam setzte sich aus Wissenschaftlern des Forschungsinstituts für biologischen Landbau (Deutschland und Schweiz), des Büros für Lebensmittelkunde, des Forschungsrings für Biologisch-Dynamische Wirtschaftsweise e.V. sowie des Fachgebiets Ökologische Lebensmittelqualität und Ernährungskultur der Universität Kassel zusammen.
In dem zeitlich sehr begrenzten Projekt fokussierte die Arbeitsgruppe die Betrachtung auf folgende Themenkomplexe und Produktgruppen:
Bereich Qualität
- Ernährung
- Sensorik
- Ökospezifische Qualitäten
- Authentizität und Rückverfolgbarkeit
Bereich Verarbeitung
- Rohwaren/Lagerung und Technologien für die Produktgruppen:
-- Getreide
-- Milch
-- Fleisch
-- Obst und Gemüse und Erzeugnisse aus diesen
- Nachhaltigkeit im Unternehmen und entlang der Prozesskette
- Verpackung
Vorhandenes Wissen, aktuelle Fragestellungen und Entwicklungsrichtungen wurden nach thematisch angepassten Vorgehensweisen identifiziert und anhand internationaler Literatur und Experteninterviews diskutiert.
Zu allen Themenkomplexen wurden kurze und allgemeinverständliche Reports erstellt, die einen schnellen und fundierten Überblick zum aktuellen Stand des Wissens und zu eventuellen Wissenslücken geben. Der Abschlussreport wurde in deutscher und englischer Sprache veröffentlicht.
Insgesamt wurde festgestellt, dass in den betrachteten Themenkomplexen erheblicher Bedarf an Forschung und Entwicklung sowie an Wissenstransfer besteht. Neben einer Reihe von Detailfragen sind grundlegende Themen, wie beispielsweise das Anforderungsprofil an eine „ökologische Verarbeitung“, nicht hinreichend erforscht und geklärt. Diese Arbeiten sind jedoch Voraussetzung für die Bearbeitung von Detailthemen, da hier Aufgabenstellungen, Schwerpunktsetzungen und Methoden definiert werden
