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ABSTRACT: Introduction: ω-3 Polyunsaturated fatty acids contained in fish oils (FO) possess major anti-inflammatory, antioxidant, and immunologic properties that could be beneficial during critical illness. We hypothesized that parenteral FO-containing emulsions may improve clinical outcomes in the critically ill. Methods: We searched computerized databases from 1980-2012. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated FO-containing emulsions, either in the context of parenteral nutrition (PN) or enteral nutrition (EN). Results: A total of 6 RCTs (n = 390 patients) were included; the mean methodological score of all trials was 10 (range, 6-13). When the results of these studies were aggregated, FO-containing emulsions were associated with a trend toward a reduction in mortality (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.49-1.04; P = .08; heterogeneity I(2) = 0%) and a reduction in the duration of mechanical ventilation (weighted mean difference in days [WMD], -1.41; 95% CI, -3.43 to 0.61; P = .17). However, this strategy had no effect on infections (RR, 0.76; 95% CI, 0.42-1.36; P = .35) and intensive care unit length of stay (WMD, -0.46; 95% CI, -4.87 to 3.95; P = .84, heterogeneity I(2) = 75%). Conclusion: FO-containing lipid emulsions may be able to decrease mortality and ventilation days in the critically ill. However, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of parenteral FO. Large, rigorously designed RCTs are required to elucidate the efficacy of parenteral FO in the critically ill.
Journal of Parenteral and Enteral Nutrition 04/2013; · 3.29 Impact Factor
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Renee D Stapleton
Critical care medicine 12/2011; 39(12):2789-90. · 6.37 Impact Factor
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ABSTRACT: Recent literature suggests that obese critically ill patients do not have worse outcomes than patients who are normal weight. However, outcomes in extreme obesity (BMI ≥ 40 kg/m(2)) are unclear. We sought to determine the association between extreme obesity and ICU outcomes.
We analyzed data from a multicenter international observational study of ICU nutrition practices that occurred in 355 ICUs in 33 countries from 2007 to 2009. Included patients were mechanically ventilated adults ≥ 18 years old who remained in the ICU for > 72 h. Using generalized estimating equations and Cox proportional hazard modeling with clustering by ICU and adjusting for potential confounders, we compared extremely obese to normal-weight patients in terms of duration of mechanical ventilation (DMV), ICU length of stay (LOS), hospital LOS, and 60-day mortality.
Of the 8,813 patients included in this analysis, 3,490 were normal weight (BMI 18.5-24.9 kg/m(2)), 348 had BMI 40 to 49.9 kg/m(2), 118 had BMI 50 to 59.9 kg/m(2), and 58 had BMI ≥ 60 kg/m(2). Unadjusted analyses suggested that extremely obese critically ill patients have improved mortality (OR for death, 0.77; 95% CI, 0.62-0.94), but this association was not significant after adjustment for confounders. However, an adjusted analysis of survivors found that extremely obese patients have a longer DMV and ICU LOS, with the most obese patients (BMI ≥ 60 kg/m(2)) also having longer hospital LOS.
During critical illness, extreme obesity is not associated with a worse survival advantage compared with normal weight. However, among survivors, BMI ≥ 40 kg/m(2) is associated with longer time on mechanical ventilation and in the ICU. These results may have prognostic implications for extremely obese critically ill patients.
Chest 08/2011; 140(5):1198-206. · 5.25 Impact Factor
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Renee D Stapleton,
Thomas R Martin,
Noel S Weiss,
Joseph J Crowley,
Stephanie J Gundel,
Avery B Nathens,
Saadia R Akhtar,
John T Ruzinski,
Ellen Caldwell,
J Randall Curtis,
Daren K Heyland,
Timothy R Watkins,
Polly E Parsons,
Julie M Martin,
Mark M Wurfel,
Teal S Hallstrand,
Kathryn A Sims,
Margaret J Neff
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ABSTRACT: Administration of eicosapentaenoic acid and docosahexanoic acid, omega-3 fatty acids in fish oil, has been associated with improved patient outcomes in acute lung injury when studied in a commercial enteral formula. However, fish oil has not been tested independently in acute lung injury. We therefore sought to determine whether enteral fish oil alone would reduce pulmonary and systemic inflammation in patients with acute lung injury.
Phase II randomized controlled trial.
Five North American medical centers.
Mechanically ventilated patients with acute lung injury ≥18 yrs of age.
Subjects were randomized to receive enteral fish oil (9.75 g eicosapentaenoic acid and 6.75 g docosahexanoic acid daily) or saline placebo for up to 14 days.
Bronchoalveolar lavage fluid and blood were collected at baseline (day 0), day 4 ± 1, and day 8 ± 1. The primary end point was bronchoalveolar lavage fluid interleukin-8 levels. Forty-one participants received fish oil and 49 received placebo. Enteral fish oil administration was associated with increased serum eicosapentaenoic acid concentration (p < .0001). However, there was no significant difference in the change in bronchoalveolar lavage fluid interleukin-8 from baseline to day 4 (p = .37) or day 8 (p = .55) between treatment arms. There were no appreciable improvements in other bronchoalveolar lavage fluid or plasma biomarkers in the fish oil group compared with the control group. Similarly, organ failure score, ventilator-free days, intensive care unit-free days, and 60-day mortality did not differ between the groups.
Fish oil did not reduce biomarkers of pulmonary or systemic inflammation in patients with acute lung injury, and the results do not support the conduct of a larger clinical trial in this population with this agent. This experimental approach is feasible for proof-of-concept studies evaluating new treatments for acute lung injury.
Critical care medicine 03/2011; 39(7):1655-62. · 6.37 Impact Factor
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ABSTRACT: Supplementation of enteral nutritional formulas and parenteral nutrition lipid emulsions with omega-3 fatty acids is a recent area of research in patients with critical illness. It is hypothesized that omega-3 fatty acids may help reduce inflammation in critically ill patients, particularly those with sepsis and acute lung injury. The objective of this article is to review the data on supplementing omega-3 fatty acids during critical illness; enteral and parenteral supplemental nutrition are reviewed separately. The results of the research available to date are contradictory for both enteral and parenteral omega-3 fatty acid administration. Supplementation with omega-3 fatty acids may influence the acute inflammatory response in critically ill patients, but more research is needed before definitive recommendations about the routine use of omega-3 fatty acids in caring for critically ill patients can be made.
Nutrition Reviews 09/2010; 68(9):531-41. · 4.47 Impact Factor
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ABSTRACT: Obesity is associated with poor outcomes in many diseases, although recent data suggest that acute lung injury (ALI) is an exception. This is particularly interesting because obesity is marked by increased levels of proinflammatory mediators associated with increased morbidity and mortality in ALI. We hypothesized that cytokine response might be attenuated in patients who are obese and critically ill or that obesity might modify the relationship between plasma cytokines and clinical outcomes in ALI.
We analyzed plasma biomarker levels (interleukin [IL]-6, IL-8, tumor necrosis factor-alpha receptor 1, surfactant protein D [SP-D], soluble intracellular adhesion molecule, von Willebrand factor (vWF), protein C, and plasminogen activator inhibitor-1) collected at baseline and day 3 in 1,409 participants in prior National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network (ARDSNet) trials. BMI was calculated for each patient, and associations with cytokine levels and ventilator-free days (VFDs), organ failure-free days (OFDs), and mortality were investigated in regression models adjusting for confounders.
In adjusted analyses, plasma IL-6 (P = .052), IL-8 (P = .001), and SP-D (P < .001) were inversely related to BMI, whereas vWF (P = .001) and WBC count (P = .042) increased proportionally with BMI. BMI was not associated with increased morbidity or mortality and did not modify the association between baseline biomarker levels and mortality, VFDs, or OFDs.
Patients who are obese and have ALI have lower levels of several proinflammatory cytokines, suggesting that the inflammatory response may be altered in patients with ALI and a high BMI. Lower SP-D but higher vWF suggests decreased epithelial and increased endothelial injury in the lung of patients who are obese. Mechanisms by which obesity may modulate innate immunity in critical illness are unclear, and future studies should elucidate such mechanisms.
Chest 09/2010; 138(3):568-77. · 5.25 Impact Factor
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ABSTRACT: Fish oil is rich in omega-3 fatty acids, which have been shown to be beneficial in multiple disease states that involve an inflammatory process. It is now hypothesized that omega-3 fatty acids may decrease the inflammatory response and be beneficial in critical illness. After a review of the mechanisms of omega-3 fatty acids in inflammation, research using enteral nutrition formulas and parenteral nutrition lipid emulsions fortified with fish oil were examined. The results of this research to date are inconclusive for both enteral and parenteral omega-3 fatty acid administration. More research is required before definitive recommendations can be made on fish oil supplementation in critical illness.
Critical care clinics 07/2010; 26(3):501-14, ix. · 1.72 Impact Factor
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ABSTRACT: It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival.
We examined fee-for-service Medicare data from 1992 through 2005 to identify beneficiaries 65 years of age or older who underwent CPR in U.S. hospitals. We examined temporal trends in the incidence of CPR and the rate of survival after CPR, as well as patient- and hospital-level predictors of survival to discharge.
We identified 433,985 patients who underwent in-hospital CPR; 18.3% of these patients (95% confidence interval [CI], 18.2 to 18.5) survived to discharge. The rate of survival did not change substantially during the period from 1992 through 2005. The overall incidence of CPR was 2.73 events per 1000 admissions; the incidence was higher among black and other nonwhite patients. The proportion of patients undergoing in-hospital CPR before death increased over time and was higher for nonwhite patients. The survival rate was lower among patients who were men, were older, had more coexisting illnesses, or were admitted from a skilled-nursing facility. The adjusted odds of survival for black patients were 23.6% lower than those for similar white patients (95% CI, 21.2 to 25.9). The association between race and survival was partially explained by hospital effects: black patients were more likely to undergo CPR in hospitals that have lower rates of post-CPR survival. Among patients surviving in-hospital CPR, the proportion of patients discharged home rather than to a health care facility decreased over time.
Survival after in-hospital CPR did not improve from 1992 through 2005. The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased. Black race was associated with higher rates of CPR but lower rates of survival after CPR.
New England Journal of Medicine 08/2009; 361(1):22-31. · 53.30 Impact Factor
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Renee D Stapleton
Respiratory care 12/2008; 53(11):1429-31. · 2.01 Impact Factor
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ABSTRACT: The goal of palliative care is to prevent suffering and manage symptoms, maintain quality of life, and provide physical, emotional, and spiritual support for patients and their loved ones. Research suggests that patients with chronic lung disease receive suboptimal palliative care largely because of inadequate communication with their physicians. When patients have made decisions about life-sustaining therapies, physicians often either do not know patients' wishes or misunderstand them. Clinicians should realize that most patients want more information about end-of-life care and that efforts to initiate and improve communication with their patients are important. This article reviews the potential for enhanced palliative care for older patients with chronic lung disease.
Clinics in Chest Medicine 01/2008; 28(4):801-11, vii. · 3.28 Impact Factor
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ABSTRACT: Hypermetabolism and malnourishment are common in the intensive care unit. Malnutrition is associated with increased morbidity and mortality, and most intensive care unit patients receive specialized nutrition therapy to attenuate the effects of malnourishment. However, the optimal amount of energy to deliver is unknown, with some studies suggesting that full calorie feeding improves clinical outcomes but other studies concluding that caloric intake may not be important in determining outcome. In this narrative review, we discuss the studies of critically ill patients that examine the relationship between dose of nutrition and clinically important outcomes. Observational studies suggest that achieving targeted caloric intake might not be necessary since provision of approximately 25% to 66% of goal calories may be sufficient. Randomized controlled trials comparing early aggressive use of enteral nutrition compared with delayed, less aggressive use of enteral nutrition suggest that providing increased calories with early, aggressive enteral nutrition is associated with improved clinical outcomes. However, energy provision with parenteral nutrition, either instead of or supplemental to enteral nutrition, does not offer additional benefits. In summary, the optimal amount of calories to provide critically ill patients is unclear given the limitations of the existing data. However, evidence suggests that improving adequacy of enteral nutrition by moving intake closer to goal calories might be associated with a clinical benefit. There is no role for supplemental parenteral nutrition to increase caloric delivery in the early phase of critical illness. Further high-quality evidence from randomized trials investigating the optimal amount of energy intake in intensive care unit patients is needed.
Critical Care Medicine 10/2007; 35(9 Suppl):S535-40. · 6.33 Impact Factor
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ABSTRACT: The association between body mass index (BMI) and outcomes in critically ill patients is unclear. Our objective was to determine the association between BMI and outcomes in a population-based cohort of patients with acute lung injury (ALI).
In a prospective cohort study of all ICU patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded. Using multivariate analysis, patients in the abnormal BMI groups were compared to normal patients in the following areas: mortality, hospital length of stay (LOS), ICU LOS, duration of mechanical ventilation, and discharge disposition.
There was no mortality difference in any of the abnormal BMI groups compared to normal-weight patients. Severely obese patients had longer hospital LOS than normal-weight patients (mean increase, 10.5 days; 95% confidence interval [CI], 4.8 to 16.2 days; p < 0.001); this was accentuated when analysis was restricted to survivors (mean increase, 14.3 days; 95% CI, 7.1 to 21.6 days; p < 0.001). ICU LOS and duration of mechanical ventilation were also longer in the severely obese group when analysis was restricted to survivors (mean increase, 5.6 days; 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 0.03). Severely obese patients were more likely to be discharged to a rehabilitation or skilled nursing facility than to home.
BMI is not associated with mortality in patients with ALI, but severe obesity is associated with increased morbidity and resource utilization in the hospital and after discharge.
Chest 03/2007; 131(2):342-8. · 5.25 Impact Factor
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ABSTRACT: The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction.
We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory.
Four Seattle hospitals.
Family members of critically ill patients.
Questionnaires rating satisfaction with communication were completed by 169 family members.
Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005).
Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.
Critical Care Medicine 07/2006; 34(6):1679-85. · 6.33 Impact Factor
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ABSTRACT: To identify risk factors for group B streptococcus (GBS) colonization in pregnancy, hypothesizing that health care workers may have increased risk.
Population-based, case-control study comparing 40,459 cases of GBS colonization, identified from Washington State birth certificate data linked to hospital discharge data for live births between 1997 and 2002, with 84,268 controls matched by year of delivery by multivariable logistic regression.
After adjustment for confounders, the following characteristics were independently associated with increased maternal GBS colonization: health care occupation (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.07-1.38), black race (OR 1.54, 95% CI 1.36-1.74), overweight (OR 1.07, 95% CI 1.01-1.12), obesity (OR 1.20, 95% CI 1.13-1.28), severe obesity (OR 1.45, 95% CI 1.28-1.63), median income greater than lowest quintile (OR 1.29, 95% CI 1.20-1.39 for fifth versus first quintile), some high school education (OR 1.21, 95% CI 1.05-1.40), high school graduate (OR 1.35, 95% CI 1.16-1.56), and adequate prenatal care (OR 1.14, 95% CI 1.06-1.24). Hispanic women (OR 0.88, 95% CI 0.80-0.96) and smokers (OR for 1-10 cigarettes per day 0.90, 95% CI 0.83-0.97) had a decreased odds of colonization.
Health care workers, black women, and women with high body mass index may be at greater risk of GBS colonization in pregnancy. However, any increases in risk are modest and the association between a health care occupation and GBS colonization needs to be investigated further.
Obstetrics and Gynecology 01/2006; 106(6):1246-52. · 4.73 Impact Factor
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Critical Care Medicine 09/2005; 33(8):1857-8. · 6.33 Impact Factor
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ABSTRACT: Since the early 1980s, case fatality of patients with ARDS has decreased, and explanations are unclear.
Using identical definitions of ARDS and organ failure, we analyzed consecutive cohorts of patients meeting syndrome criteria at our institution in 1982 (n = 46), 1990 (n = 112), 1994 (n = 99), and 1998 (n = 205) to determine causes and timing of death.
Overall case fatality has decreased from 68% in 1981-1982 to a low of 29% in 1996, plateauing since the mid-1990s (p = 0.001 for trend). Sepsis syndrome with multiple organ failure remains the most common cause of death (30 to 50%), while respiratory failure causes a small percentage (13 to 19%) of deaths. The distribution of causes of death has not changed over time. There was no change in the timing of death during the study periods: 26 to 44% of deaths occurred early (< 72 h after ARDS onset), and 56 to 74% occurred late (> 72 h after ARDS onset). However, the increased survival over the past 2 decades is entirely accounted for by patients who present with trauma and other risk factors for their ARDS, while survival for those patients whose risk factor is sepsis has not changed. Additionally, withdrawal of life support in these patients is now occurring at our institution significantly more frequently than in the past, and median time until death has decreased in patients who have support withdrawn.
While these results do not explain the overall case fatality decline in ARDS, they do indicate that sepsis syndrome remains the leading cause of death and suggest that future therapies to improve survival be targeted at reducing the complications of sepsis.
Chest 08/2005; 128(2):525-32. · 5.25 Impact Factor
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ABSTRACT: Depressive symptoms and reduced health-related quality of life are common in patients with severe COPD. Therefore, understanding the association between preferences for life-sustaining treatment and depression or quality of life is important in providing care. No prior studies have examined the effects of depression and quality of life on treatment preferences in this population.
Cross-sectional study of 101 patients with oxygen-prescribed COPD.
Patients completed the St. George's Respiratory Questionnaire, Center for Epidemiologic Studies-Depression survey, and questions regarding their preferences for mechanical ventilation and cardiopulmonary resuscitation if needed to sustain life.
Median age was 67.4 years, and median FEV1 was 26.3% predicted. Depression was significantly associated with preferences for resuscitation (50% of depressed patients and 23% of patients without depression refused resuscitation; p = 0.007), but was not associated with preferences for mechanical ventilation. Health-related quality of life was not associated with preferences for either resuscitation or mechanical ventilation.
Clinicians caring for patients with oxygen-prescribed COPD should understand that health-related quality of life does not predict treatment preferences and should not influence clinicians' views of patients' treatment preferences. However, depression does appear to influence patients' treatment decisions for cardiopulmonary resuscitation, and improvement in depressive symptoms should trigger a reassessment of these preferences.
Chest 02/2005; 127(1):328-34. · 5.25 Impact Factor
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ABSTRACT: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP).
An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis.
There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas.
This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
Critical Care Medicine 01/2005; 32(12):2524-36. · 6.33 Impact Factor
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Proceedings of the American Thoracic Society 02/2004; 1(4):289-90.
