End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.

End-of-life care in the intensive care unit (ICU) was identified as an objective in a series of Task Forces developed by the World Federation of Societies of Intensive and Critical Care Medicine Council in 2014. The objective was to develop a generic statement about current knowledge and to identify challenges relevant to the global community that may inform regional and local initiatives. An updated summary of published statements on end-of-life care in the ICU from national Societies is presented, highlighting commonalities and differences within and between international regions. The complexity of end-of-life care in the ICU, particularly relating to withholding and withdrawing life-sustaining treatment while ensuring the alleviation of suffering, within different ethical and cultural environments is recognized. Although no single statement can therefore be regarded as a criterion standard applicable to all countries and societies, the World Federation of Societies of Intensive and Critical Care Medicine endorses and encourages the role of Member Societies to lead the debate regarding end-of-life care in the ICU within each country and to take a leading role in developing national guidelines and recommendations within each country.

Organ donation in adults: a critical care perspective.

PURPOSE: The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure. METHODS: We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria. RESULTS: Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques. CONCLUSIONS: Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

Reducing interruptions to continuous enteral nutrition in the intensive care unit: a comparative study.

AIMS AND OBJECTIVES: To develop and test strategies to reduce interruptions to enteral feeding to improve practice and promote attainment of nutritional goals. BACKGROUND: Enteral nutrition is preferred for feeding patients in the intensive care unit who are unable to have oral nutrition. Interruption to feeding is likely to be a major contributor to patients not receiving their prescribed nutrition goals. DESIGN: Prospective before (May-November 2009) and after (March-September 2010) study. METHOD: Patients admitted to the intensive care unit (except cardiac surgery) and who were eligible to receive enteral nutrition were enrolled. After gaining Ethics Committee approval, baseline data were collected to identify interruptions to enteral nutrition. Nurse-led multidisciplinary teams developed interventions to target specific reasons for interruption. Change champions implemented the improvements after staff were provided with an education package. Postintervention data were then collected. RESULTS: Six hundred and fifty-three patients received enteral nutrition with the majority (88%) fed within 48 hours. Considering the first 28 days of feeding for patients fed longer than 24 hours (505 patients), the number of interruptions for patients who had an interruption decreased from 907-662. Interruptions due to gastrointestinal issues decreased (14 vs 10%), while those due to airway issues, enteral nutrition delivery system problems and other interruptions were similar before-and-after the practice change. Time lost to feeding because of interruptions was similar between groups. CONCLUSION: Targeted strategies to enteral feeding practice resulted in a reduction to the number of interruptions but not the duration of enteral nutrition lost to interruption. Reducing unnecessary interruption of feeding circuits is likely to minimise the risk for splash injury and contamination of feeding sets through less manipulation and interruption to enteral nutrition flow. RELEVANCE TO CLINICAL PRACTICE: Review of practice may reveal opportunities for improvement. Nurse champions can facilitate change processes to improve care.

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

We examined the effect of introducing a discharge plan on the occurrence of adverse events within 72 hours of intensive care unit discharge. The study excluded discharges to home or to another institution and "not-for-resuscitation" patients. The adverse events rate was 23%, of which 37% were considered to be preventable. Respiratory problems and infections were the most frequent reasons. The discharge plan contributed to a change in the nature and preventability of events and facilitates the discharge process.

Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial.

CONTEXT: Evidence demonstrates that providing nutritional support to intensive care unit (ICU) patients within 24 hours of ICU admission reduces mortality. However, early feeding is not universally practiced. Changing practice in complex multidisciplinary environments is difficult. Evidence supporting whether guidelines can improve ICU feeding practices and patient outcomes is contradictory. OBJECTIVE: To determine whether evidence-based feeding guidelines, implemented using a multifaceted practice change strategy, improve feeding practices and reduce mortality in ICU patients. DESIGN, SETTING, AND PATIENTS: Cluster randomized trial in ICUs of 27 community and tertiary hospitals in Australia and New Zealand. Between November 2003 and May 2004, 1118 critically ill adult patients expected to remain in the ICU longer than 2 days were enrolled. All participants completed the study. INTERVENTIONS: Intensive care units were randomly assigned to guideline or control groups. Guideline ICUs developed an evidence-based guideline using Browman's Clinical Practice Guideline Development Cycle. A practice-change strategy composed of 18 specific interventions, leveraged by educational outreach visits, was implemented in guideline ICUs. MAIN OUTCOME MEASURES: Hospital discharge mortality. Secondary outcomes included ICU and hospital length of stay, organ dysfunction, and feeding process measures. RESULTS: Guideline and control ICUs enrolled 561 and 557 patients, respectively. Guideline ICUs fed patients earlier (0.75 vs 1.37 mean days to enteral nutrition start; difference, -0.62 [95% confidence interval {CI}, -0.82 to -0.36]; P < .001 and 1.04 vs 1.40 mean days to parenteral nutrition start; difference, -0.35 [95% CI, -0.61 to -0.01]; P = .04) and achieved caloric goals more often (6.10 vs 5.02 mean days per 10 fed patient-days; difference, 1.07 [95% CI, 0.12 to 2.22]; P = .03). Guideline and control ICUs did not differ with regard to hospital discharge mortality (28.9% vs 27.4%; difference, 1.4% [95% CI, -6.3% to 12.0%]; P = .75) or to hospital length of stay (24.2 vs 24.3 days; difference, -0.08 [95% CI, -3.8 to 4.4]; P = .97) or ICU length of stay (9.1 vs 9.9 days; difference, -0.86 [95% CI, -2.6 to 1.3]; P = .42). CONCLUSIONS: Using a multifaceted practice change strategy, ICUs successfully developed and introduced an evidence-based nutritional support guideline that promoted earlier feeding and greater nutritional adequacy. However, use of the guideline did not improve clinical outcomes. Trial Registration anzctr.org.au Identifier: ACTRN12608000407392.

Caspofungin for the treatment of less common forms of invasive candidiasis.

OBJECTIVES: Caspofungin has demonstrated efficacy in invasive candidiasis. However, in a comparative study, most patients (>83%) had candidaemia. Therefore, we performed a study in patients with non-fungaemic invasive candidiasis. PATIENTS AND METHODS: Adults with proven non-fungaemic invasive candidiasis or probable chronic disseminated candidiasis (CDC) received caspofungin primary or salvage monotherapy. Most patients received 50 mg daily following a 70 mg loading dose. Patients with endocarditis, osteomyelitis or septic arthritis received caspofungin at 100 mg daily and were allowed dose escalation up to 150 mg. Primary efficacy endpoint was the overall response at end of caspofungin therapy. A favourable overall response required complete resolution of symptoms and either eradication of Candida or radiographic resolution. RESULTS: All 48 patients enrolled had confirmed infection and received>or=1 dose of caspofungin. At study entry, 8% were neutropenic. The mean APACHE II score was 14.3. Most infections were due to Candida albicans (60%) or Candida glabrata (14%). The overall success at end of caspofungin therapy was 81%. Success by site of infection was as follows: peritonitis 77% (10/13), abdominal abscess 89% (8/9), CDC 88% (7/8), osteomyelitis/septic arthritis 100% (4/4), endocarditis 33% (1/3) and multiple sites 75% (6/8). Outcomes were similar across Candida spp. None of the patients had a serious drug-related adverse event or discontinued caspofungin due to toxicity. Overall mortality until 12 week follow-up was 23%. CONCLUSIONS: In deep-seated invasive candidiasis, including peritonitis, abdominal abscesses, CDC and arthritis, caspofungin was effective and safe at regular doses and up to 100 mg daily.