Does enteral nutrition protect against stress ulceration in the critically ill?

Purpose Of Review: Critically ill patients are at risk of gastrointestinal bleeding (GIB) due to stress ulceration. Strategies to reduce the risk include administration of prophylactic ulcer healing medications. Enteral nutrition (EN) may be favourably associated with GIB risks.

Consequences of anemia in geriatric hip fractures: how low is too low?

Background: The transfusion threshold for low hemoglobin (Hgb) in geriatric patients with hip fractures is widely debated. In certain populations, low Hgb is associated with poor outcomes. Our objective was to evaluate the relationship between lowest Hgb and outcome to identify the Hgb threshold where poor outcomes were more prevalent.

Management of Heat-Related Illness and Injury in the ICU: A Concise Definitive Review.

Objectives: The increasing frequency of extreme heat events has led to a growing number of heat-related injuries and illnesses in ICUs. The objective of this review was to summarize and critically appraise evidence for the management of heat-related illnesses and injuries for critical care multiprofessionals.

Data Sources: Ovid Medline, Embase, Cochrane Clinical Trials Register, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.

In-Hospital Violence and Its Impact on Critical Care Practitioners.

Objectives: To provide a narrative review of hospital violence (HV) and its impact on critical care clinicians.

Data Sources: Detailed search strategy using PubMed and OVID Medline for English language articles describing HV, risk factors, precipitating events, consequences, and mitigation strategies.

Study Selection: Studies that specifically addressed HV involving critical care medicine clinicians or their practice settings were selected.

Reversal of pre-injury factor-Xa inhibitors with prothrombin complex concentrates in patients following traumatic brain injury.

Introduction: There is substantial debate on the best method to reverse factor Xa-inhibitors in patients following traumatic brain injury (TBI). Prothrombin complex concentrates (PCC) have been used for this indication but their role has been questioned. This study reported failure rates with PCC in patients following TBI and as a secondary objective, compared 4-factor (4 F-PCC) and activated PCC (APCC).

A Systematic Approach to Understanding Acid-Base Disorders in the Critically Ill.

Objective: The objective of this review is to discuss acid-base physiology, describe the essential steps for interpreting an arterial blood gas and relevant laboratory tests, and review the 4 distinct types of acid-base disorders.

Data Sources: A comprehensive literature search and resultant bibliography review of PubMed from inception through March 7, 2023.

Study Selection And Data Extraction: Relevant English-language articles were extracted and evaluated.

Prophylactic acid suppression and enteral nutrition.

Purpose Of Review: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients who are at high-risk for clinically important gastrointestinal bleeding. Recent evidence however has highlighted adverse effects with acid suppressive therapy, particularly proton pump inhibitors where associations with higher mortality have been reported. Enteral nutrition may provide benefits in reducing the incidence of stress ulceration and may mitigate the need for acid suppressive therapy.

Pharmacologic venous thromboembolism prophylaxis in obese trauma patients.

Purpose: To review the evidence cited in recent consensus documents providing recommendations for drug dosing for venous thromboembolism (VTE) prophylaxis in obese trauma patients.

Summary: Recent publications from the American Association for the Surgery of Trauma and the American College of Surgeons provide recommendations for VTE prophylaxis in trauma. These documents address key aspects of pharmacologic prophylaxis, one of which is drug dosing in obesity.

Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity.

Objective: The objective of the study was to discuss the controversies surrounding the use and dosing of direct-acting oral anticoagulants (DOACs) in obese patients recognizing the limitations of the existing evidence base that preclude strong recommendations.

Data Sources: A literature search of MEDLINE was performed (2020 to end August 2022) subsequent to recent guidelines using the following search terms: , and .

Study Selection And Data Abstraction: English-language studies and those conducted in adults were selected.

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications.

Background: Fascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy.

Challenges With Using a Weight-Based Approach to Bolus Fluid Dosing in Obese Critically Ill Patients.

At least 30 mL/kg of crystalloid fluid administration within the first 3 hours of resuscitation is suggested by the current Surviving Sepsis Campaign guidelines for management of sepsis and septic shock. This commentary discusses the challenges with using a weight-based approach to bolus fluid dosing during the early phase of resuscitation of adult, obese patients. Based on the available literature, arguments can be made for the use of either ideal or adjusted body weight for weight-based fluid dosing, but there are concerns with fluid overload if using actual body weight to dose patients with more severe forms of obesity.

Dosing Medications for Coagulopathy Reversal in Patients with Extreme Obesity.

Background: The reversal of anticoagulant or antiplatelet medications is a priority in the management of patients with severe injury with the goal of minimizing further bleeding without thrombotic complications. There are few studies, however, evaluating the dosing of reversal agents in the setting of trauma specific to patients with extreme obesity. Nevertheless, clinicians must still make decisions, balancing concerns of ongoing bleeding with excessive thrombosis.

Pitfalls and pearls with drug dosing in the critically ill obese patient: 10 statements to guide ICU practitioners.

Obesity is highly prevalent in ICU patients presenting a number of challenges, one of which is drug dosing. There are limited high-quality data describing drug dosing in obesity, which can lead to dosing strategies that are suboptimal. For example, inappropriately using the wrong weight for weight-based dosing can lead to supratherapeutic drug concentrations and an adverse drug event or subtherapeutic drug concentrations and treatment failure.

N -acetylcysteine is associated with reduction of postconcussive symptoms in elderly patients: A pilot study.

Introduction: N -acetylcysteine (NAC) may be neuroprotective by minimizing postconcussion symptoms after mild traumatic brain injury (TBI), but limited data exist. This study evaluated the effects of NAC on postconcussion symptoms in elderly patients diagnosed with mild TBI.

Methods: This prospective, quasirandomized, controlled trial enrolled patients 60 years or older who suffered mild TBI.

Drug dosing in hospitalized obese patients with COVID-19.

Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect.

Implications of obesity for drug administration and absorption from subcutaneous and intramuscular injections: A primer.

Purpose: To discuss the potential implications of obesity for drug administration and absorption from subcutaneous (SC) and intramuscular (IM) injection sites.

Summary: The SC and IM routes are useful for the parenteral administration of medications to optimize pharmacokinetic properties such as time to onset and duration of effect, for cost considerations, or for ease of administration, such as when intravenous access is unavailable. The choice of SC or IM injection depends on the specific medication, with SC administration preferred for products such as insulin where a slower and more sustained response is desirable, while IM administration is usually preferred for products such as vaccines where more rapid absorption leads to a more rapid antibody response.