Manual Caring for the Seriously Ill Patient 2E: Volume 1

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Comparisons between 14 people with sepsis to 9 similar patients without sepsis documented a significant loss of diaphragm muscle volume compared with the psoas muscle volume in the septic patients. The loss of diaphragm muscle was associated with loss of strength. Comparisons between 14 people with sepsis and 9 similar patients without sepsis documented a significant loss of diaphragm muscle volume compared with the psoas muscle volume in the septic patients. Anesthesiology ; 5 We have emailed you at with instructions on how to set up a new password.

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The first two authors contributed equally to this work B. Submitted for publication August 5, Accepted for publication January 24, Correspondence: Address correspondence to Dr. Information on purchasing reprints may be found at www. Article Information. Anesthesiology 05 , Vol.

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You will receive an email whenever this article is corrected, updated, or cited in the literature. You can manage this and all other alerts in My Account. You must be logged in to access this feature. THE diaphragm is the main respiratory muscle, its dysfunction is one of the main causes of difficulties to wean from the ventilator in the intensive care unit ICU and sepsis affects its contractility in the critically ill.

However, these survivors increasingly present profound skeletal muscle weakness and there is a need to better identify and treat sepsis-induced myopathy in the critically ill patients.

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The aims of our study were therefore to compare diaphragm and psoas volumes between septic and nonseptic critically ill patients during the ICU stay and to describe the relation between diaphragm volume and diaphragm contractility in critically ill patients. We hypothesized that sepsis is associated with a preferential diaphragmatic atrophy, which is negatively correlated with diaphragm contractility.

This study was conducted from July to August in a bed medical—surgical ICU Saint Eloi Teaching Hospital ICU, Montpellier, France and is a retrospective secondary analysis of a trial performed with some of the patients critically ill patients. The study design is represented in figure 1. Design of the study. Diaphragm force evaluation and the first computed tomography CT volume measurement were performed upon intensive care unit ICU admission. A flow chart of the study is represented in figure 2.

Critically ill patients were included in the post hoc analysis if they were admitted to the ICU and had had 1 an abdominal CT scan before the ICU admission, 2 a second abdominal CT scan during the ICU stay, and 3 at least one measure of diaphragmatic contractility by measuring the change in endotracheal tube pressure induced by application of bilateral magnetic twitch stimulation of the phrenic nerves during airway occlusion TwPtr while being intubated.

Table 1. One radiologist S. The radiologist manually traced the diaphragm borders, and then the volumetry software calculated the whole diaphragm volume using an algorithm summing up each of the cross-sectional volumes multiply cross-sectional area by section thickness. The psoas volumes were measured with the same technique. In the critically ill, abdominal wall and paraspinal muscle cross-sectional area were measured at the level of the third lumbar vertebra as described elsewhere.

Psoas and diaphragm volume measurements with three-dimensional computed tomography reconstruction and dedicated software for volumetry measurement Advantage Window 4.

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Cross-sectional area of the paraspinal and abdominal wall muscles was measured at the level of the third lumbar vertebra average cross sectional area Diaphragmatic contractile function was evaluated as previously described. TwPtr was obtained upon ICU admission but not afterwards as detailed in a previous study from our group. The primary endpoint was to compare diaphragm and psoas volume changes between septic and nonseptic critically ill patients.

The secondary endpoint was to describe the relation between diaphragm volume and diaphragm contractility. Demographic characteristics, muscle volumes, and muscle surfaces were compared between controls, nonseptic, and septic patient groups using the Kruskall—Wallis, repeated-measure ANOVA, or chi-square tests according to the distribution of the variables. To compare volume kinetic in the critically ill according to the presence or the absence of sepsis, the Wilcoxon rank sum test for paired data was used.

The Pearson correlation coefficient was used to assess the correlation between the muscle volume and weight, height, body mass index, and contractility. After preliminary measures conducted for the current study, we assumed a mean diaphragm volume of approximately cm 3 with an SD of 60 cm 3 in the control patients. A P value of less than 0. A total of 40 patients were included.

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Seventeen constituted the control group and 23 in the ICU group; of the ICU group, 14 of them were septic and 9 were not septic fig. Table 1 shows their main characteristics. No differences were observed among septic and nonseptic patients. Sepsis started 2 days 3 to 5 before ICU admission. Nine of the 14 septic patients presented with an intraabdominal infection, 4 presented with a pneumonia, and 1 presented with an endocarditis. Among the nine patients without sepsis, three were admitted for multiple trauma, three for scheduled esophageal surgery, one for acute on chronic respiratory failure, and two for acute liver failure.

Guide to supportive care in critical illness - EMCrit Project

Diaphragm and psoas volumes were both correlated with weight, height, and body mass index fig. Scatterplot showing the results of regression analysis of diaphragm volume and patient weight A , B height, and C body mass index. Correlation was calculated for the entire sample critically ill and controls. There was a linear correlation between total diaphragm volume and weight, height, and body mass index.

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Scatterplot showing the result of regression analysis of psoas volume and intensive care unit patient weight D , height E , and body mass index F. There was a linear correlation between total psoas volume and weight, height, and body surface area. The second volume measurement was performed 25 15 to 36 days after the first measurement. No correlation was found between diaphragm or psoas volume loss and time between the two CTs. Cross-sectional areas of skeletal muscles at the level of the third lumbar vertebra did not significantly decrease during the ICU stay first measurement: When the volume drop between the two measures was considered, septic patients experienced a larger decrease of diaphragmatic volume compared with that by the nonseptic patients fig.

On the contrary, comparing changes in psoas volume and muscle surface on the level of the third lumbar vertebra between septic and nonseptic patients revealed no differences fig. A Diaphragm volume kinetic between the two volume measurements in nonseptic patients and septic patients.

B Psoas volume kinetic between the two volumes measurements in nonseptic patients and septic patients. Volume drop did not differ between the two groups. Avoid maintenance fluids. Most patients will receive plenty of fluid via medications, infusions, and enteral nutrition. Patients will usually retain fluid, so they will generally tend to develop fluid overload.

Fluid should be given only if, after careful examination often with ultrasound and review of the clinical history, there is evidence of true volume depletion. Lactate elevation may occur for numerous reasons, most of which have little to do with volume status e. A rising lactate level calls for global re-evaluation of the patient, not knee-jerk fluid administration. Don't check central venous pressure or use this to guide volume resuscitation.

Central venous pressure doesn't correlate with volume status or fluid responsiveness. Don't be afraid to use LR in hyperkalemia, since it's a great fluid for hyperkalemic renal failure. These patients will benefit from aggressive diuresis if tolerated. Use of furosemide alone tends to cause excretion of dilute urine, causing hypernatremia.