EuAsia Day 3: Metabolic issues

Hyponatraemia: European guidelines (E Hoste)

Proportion of ICU pts with hypoNa (<135) – 14 to 27%

Acute hypoNa – < 48hrs

Symptoms variable

Guideline recommends treating for severe symptomatic hypoNa with 150mls of 3%NaCl over 20 minutes, aim for Na increase of 5mmol/L

Aim to correct severe hypoNa by 10mmol/L in D1 (8mmol/L D2) until pt asymptomatic or Na >130

IF corrected too quickly – add in 5% dextrose and/or consider desmopressin 2mcg (per 8hr)

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References:

Clinical practice guideline on diagnosis and treatment of hyponatraemia

 

Nutrition in ICU (Ostermann)

Malnutrition is associated with poor outcome

Critically ill patients lose 10-20% of body protein within a week

Resting energy expenditure – Estimation/Harris and Benedikt/Indirect calorimetry

TICACOS trial – enteral feeding with energy target determined by estimation (control) vs indirect calorimetry

  • Improved survival in pts where targets were met
  • Better outcomes in control group (estimation 25kcal/kg/day)

CALORIES Trial (TPN)

  • No significant difference in groups

ESICM Guidelines (2017)

  • Early enteral nutrition as a default
  • Delay enteral nutrition in specific cases e.g. uncontrolled shock, bowel ischaemia, life threatening hypoxaemia/hypercapnia/acidosis
  • Not to delay EN in prone position

ASPEN (2016)

  • PN initiated ASAP in high risk groups if EN not feasible
  • PN can be considered in low risk pts after 7-10 days if unable to meet >60% energy goal
  • Immune0modulating enteral formulation should be considered in pts with severe trauma or TBI or post-operatively

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References:

The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

 

Liver failure: how to support (Gruber)

Liver dysfunction common but acute liver failure is rarer

Liver dysfunction post immunotherapy (as part of cancer treatment) is not uncommon

  • Supportive care
  • Steroids 1-2mg/kg/day

Commonest cause on ICU – sepsis

Cirrhotic pts have vascular hypo-reactivity due to increase NO levels

Relative adrenal insufficiency is common

Septic liver pts

  • Supportive
  • Prophylaxis – encephalopathy, GI bleeds, infection
  • High risk of fungal infection

Acute variceal haemorrhage

  • oesophageal varices common
  • Peak re-bleed day 5
  • Endoscopic and interventional radiology interventions
  • Reduction of portal pressure – octreotide, somastatin etc

AKI common but majority is NOT hepato-renal syndrome (HRS)

  • 2 types of HRS: type 1 rapid and poorer outcomes
  • Specifically for HRS: albumin/terlipressin
  • RRT as a bridge (consider citrate)

Liver support systems

  • MARS, RELIEF, PROMETHIUS
  • Failed to show mortality benefits

References:

Acute-on-chronic liver failure definitions

Acute esophageal variceal bleeding: Current strategies and new perspectives