Nutritional assessment in critically III patients

Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit [ICU] on the days of admission and discharge via a detailed nutritional assessment

Methods: Totally, 125 patients were followed up from admission to discharge at SICUs in Shiraz, Iran. The patients' nutritional status was assessed using subjective global assessment [SGA], anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated

Results: Malnutrition prevalence significantly increased on the day of discharge [58.62%] compared to the day of admission [28.8%] according to SGA [P<0.001]. The patients' weight, mid-upper-arm circumference, mid-arm muscle circumference, triceps skinfold thickness, and calf circumference decreased significantly as well [P<0.001]. Lean mass weight and body cell mass also decreased significantly [P<0.001]. Biochemical indices showed no notable changes except for magnesium, which decreased significantly [P=0.013]. A negative significant correlation was observed between malnutrition on discharge day and anthropometric measurements. Positive and significant correlations were observed between the number of days without enteral feeding, days delayed from ICU admission to the commencement of enteral feeding, and the length of ICU stay and malnutrition on discharge day. Energy and protein intakes were significantly less than the prescribed diet [26.26% ancf 26.48%, respectively]

Conclusion: Malnutrition on discharge day increased in the patients in the ICU according to SGA. Anthropometric measurements were better predictors of the nutritional outcome of our critically ill patients than were biochemical tests

Enlarged right atrium falsely interpreted as a mediastinal mass: a case report

Right atrial dilation due to left heart disease is a common complication among adults. The present review aimed to describe a case of massively dilated right atrium in a female patient presenting with valvular heart disease and no atrial fibrillation. The results of chest X-ray revealed a large opacity filling the lower right hemithorax, falsely interpreted as a mediastinal mass. During the transesophageal echocardiography, severe enlargement of the right atrium was detected, and open mitral and tricuspid valve replacements were performed successfully

Early acute kidney injury based on serum creatinine or cystatin C in intensive care unit after major trauma

Background: Acute kidney injury [AKI] is a common problem in critically ill patients and is independently associated with increased morbidity and mortality. Recently, serum cystatin C has been shown to be superior to creatinine in early detection of renal function impairment. We compared estimated GFR based on serum cystatin C with estimated GFR based on serum creatinine for early detection of renal dysfunction according to the RIFLE criteria

Methods: During 9months, three hundred post trauma patients that were referred to the intensive care unit of a referral trauma hospital were recruited. Serum creatinine and serum cystatin C were measured and the estimated GFR within 24 hours of ICU admission was calculated. The primary outcome was the incidence of AKI according to the RIFLE criteria within 2[nd] to 7[th] day of admission

Results: During the first week of ICU admission, 21% of patients experienced AKI. After adjusting for major confounders, only the patients with first day's serum cystatin level higher than 0.78mg/l were at higher risk of first week AKI [OR=6.14, 95% CI: 2.5-14.7, P<0.001]. First day's serum cystatin C and injury severity score were the major risk factors for ICU mortality [OR=3.54, 95% CI: 1.7-7.4, P=0.001] and [OR=4.6, 95% CI: 1.5-14, P=0.007], respectively

Conclusion: Within 24 hours after admission in ICU due to multiple trauma, high serum cystatin C level may have prognostic value in predicting early AKI and mortality during ICU admission. However, such correlation was not seen neither with creatinine nor cystatin C based GFR

Erythropoietin plus methylprednisolone or methylprednisolone in the treatment of acute spinal cord injury: a preliminary report

Recent studies in animal models indicate that recombinant human erythropoietin [rhEPO] is very effective in enhancing neurological recovery after spinal cord injury [SCI]. We aimed to evaluate the effect of rhEPO plus methylprednisolone sodium succinate [MPSS] compared to MPSS alone to improve neurological function of patients after SCI in a randomized clinical trial. During a 15-month period 30 patients presenting to emergency departments of two university affiliated hospitals within less than 6 hours after acute SCI were randomized to two groups. Both groups received MPSS 30 mg/kg initially and 5.4 mg/kg every hour till 23 hours if admitted within 3 hours and till 47 hours if recruited within 3-6 hours after injury. Group EPO also received 500unit/kg rhEPO on admission and another 500 unit/kg 24 hours later instead of placebo in group MPSS. Neurologic evaluation was performed on admission, 24, 48, 72 hours and one and 6 months later. Range of patients' age was 18-65 years. There was no significant difference between patients receiving two types of treatment in neurological exam on admission [P=0.125], 24 hours after admission [P=0.108] and 48 hours after admission [P=0.085]. However, one week [P=0.046], one month [P=0.021] and six months [P=0.018] after admission these differences were significant. MPSS plus rhEPO started within 6 hours after acute spinal injury may be more effective than MPSS plus placebo in improvement of neurologic dysfunction. More studies with larger sample sizes are warranted

new method for prediction of the hospitalization period in icu using neural networks

Introduction:APACHE [Acute Physiologic and Chronic Health Evaluation] score is a medical tool designed to measure the severity of disease for adult patients admitted to Intensive Care Units [ICU]. However, it is designed based on the American patients' data and is not well suited to be used for Iranian people. In addition, Iranian hospitals are not equipped with High Dependency Units which is required for original APACHE

Method: We aimed to design an intelligent version of APACHE system for recognition of patients' hospitalization period in ICUs. The new system can be designed based on Iranian local data and updated locally. Intelligence means that the system has the ability to learn from its previous results and doesn't need manual update

Results: In this study, this new system is introduced and the technical specifications are presented. It is based on neural networks. It can be trained and is capable of auto-learning. The results obtained from final implemented software show better performance than those obtained from non-local version

Conclusion: Using this method, the efficiency of the prediction has increased from 80% to 90%. Such results were compared with the APACHE outputs to show the superiority of the proposed method Keywords: Health status indicators, Hospitalization, Intensive care unit, Classification system, Neural networks

Pneumomediastinitis following internal jugular vein central line insertion: case report and review of literature

Complications related to central venous catheters [CVCs] in the postoperative period can be fatal. We recently had a case of pneumomediastinitis. A 77 years old woman with left femoral neck fracture due to a fall was admitted to Rajaee Hospital. The next day after the operation the patient presented with tachypnea and respiratory distress. Tracheal intubation was performed and mechanical ventilation was started. The central line was inserted in left internal jugular vein. Anteroposterior chest radiography revealed air space shadowing in left lung at middle and lower lobes probably due to infiltration, consolidation or collapse. The CT scan reported that pneumomediastinum was detected in superior and anterior of mediastinum. Minimal pleural effusion and consolidation was also detected in right. Lung, especially in the dependent area. The tip of the catheter was seen at the anterior part of mediastinum. Clinical findings described before declared that the patient had suffered from aspiration pneumonia which may have been occurred during the surgery. The central venous line was removed after proving its malpositioning. The patient recovered with conservative treatment and was discharged from the hospital six days after surgery. This case highlights the clinical importance of comparing CT scan to the chest x-ray accuracy in diagnosing the chest complications

Effect of timing of morphine administration during propofol - remifentanil anesthesia on the requirements of post-operative analgesia / 대한마취과학회지

BACKGROUND: An important concern of intra-operative infusion of remifentanil is the possible development of acute opioid tolerance, which manifests as an increased postoperative analgesia requirement. We have examined the effect of the timing of intra operative morphine administration on the need for morphine consumption for pain control during the first 24 hours after operation. METHODS: Sixty adult patients scheduled for elective open unilateral nephrolithotomy surgery were recruited for this prospective randomized double-blind study. Anesthesia was induced with 0.03 mg/kg midazolam, 1 microg/kg remifentanil, and 1.5-2 mg/kg propofol. Anesthesia was maintained with 100 microg/kg/min propofol, and 0.25 microg/kg/min remifentanil. Both groups received 0.1 mg/kg morphine intravenously at 2 different times; in the first group (group E) immediately after intubation and in the second group (group L) 20-30 min before the anticipated end of operation. RESULTS: There was no difference in pain scores at awakening, the amount of morphine given to the 2 groups for pain control, or the time to discharge from PACU between the 2 groups. The pain scores at admission to ward and at every 4 hours thereafter, until 24 hours, were not significantly different between the 2 groups. The cumulative amount of the first 24 hours morphine consumption in the ward in E group was 28.2 +/- 20.1 mg and 26.5 +/- 15 mg in L group, respectively (P = 0.71). CONCLUSIONS: Early intra-operative administration of morphine compared to that of morphine in the end of surgery did not affect postoperative morphine consumption and pain scores during the first 24 hours after surgery for open nephrolithotomy. Newer pharmacologic interventions for prevention of acute tolerance of opioids seems rational (Clinical trial registration No. ACTRN: 12609000570280).