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Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine
Background
Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies.
Methods
This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds.
Results
Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness.
Conclusions
Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.
Journal Article
Critical thinking and language : the challenge of generic skills and disciplinary discourses
\"This book clarifies the idea of critical thinking by investigating the 'critical' practices of academics across a range of disciplines. Drawing on key theorists -- Wittgenstein, Geertz, Williams, Halliday -- and using a 'textographic' approach, the book explores how the concept of critical thinking is understood by academics and also how it is constructed discursively in the texts and practices they employ in their teaching. Critical thinking is one of the most widely discussed concepts in debates on university learning. For many, the idea of teaching students to be critical thinkers characterizes more than anything else the overriding purpose of 'higher education'. But whilst there is general agreement about its importance as an educational ideal, there is surprisingly little agreement about what the concept means exactly. Also at issue is how and what students need to be taught in order to be properly critical in their field. This searching monograph seeks answers to these important questions.\"--Publisher's website.
Book
Acute Outcomes and 1-Year Mortality of Intensive Care Unit–acquired Weakness. A Cohort Study and Propensity-matched Analysis
Intensive care unit (ICU)-acquired weakness is a frequent complication of critical illness. It is unclear whether it is a marker or mediator of poor outcomes.
To determine acute outcomes, 1-year mortality, and costs of ICU-acquired weakness among long-stay (≥8 d) ICU patients and to assess the impact of recovery of weakness at ICU discharge.
Data were prospectively collected during a randomized controlled trial. Impact of weakness on outcomes and costs was analyzed with a one-to-one propensity-score-matching for baseline characteristics, illness severity, and risk factor exposure before assessment. Among weak patients, impact of persistent weakness at ICU discharge on risk of death after 1 year was examined with multivariable Cox proportional hazards analysis.
A total of 78.6% were admitted to the surgical ICU; 227 of 415 (55%) long-stay assessable ICU patients were weak; 122 weak patients were matched to 122 not-weak patients. As compared with matched not-weak patients, weak patients had a lower likelihood for live weaning from mechanical ventilation (hazard ratio [HR], 0.709 [0.549-0.888]; P = 0.009), live ICU (HR, 0.698 [0.553-0.861]; P = 0.008) and hospital discharge (HR, 0.680 [0.514-0.871]; P = 0.007). In-hospital costs per patient (+30.5%, +5,443 Euro per patient; P = 0.04) and 1-year mortality (30.6% vs. 17.2%; P = 0.015) were also higher. The 105 of 227 (46%) weak patients not matchable to not-weak patients had even worse prognosis and higher costs. The 1-year risk of death was further increased if weakness persisted and was more severe as compared with recovery of weakness at ICU discharge (P < 0.001).
After careful matching the data suggest that ICU-acquired weakness worsens acute morbidity and increases healthcare-related costs and 1-year mortality. Persistence and severity of weakness at ICU discharge further increased 1-year mortality. Clinical trial registered with www.clinicaltrials.gov (NCT 00512122).
Journal Article
Critical Thinking Across the Curriculum: A Vision
This essay offers a comprehensive vision for a higher education program incorporating critical thinking across the curriculum (CTAC) at hypothetical Alpha College, employing a rigorous detailed conception of critical thinking called “The Alpha Conception of Critical Thinking”. The program starts with a 1-year, required, freshman course, two-thirds of which focuses on a set of general critical thinking dispositions and abilities. The final third uses subject-matter issues to reinforce general critical thinking dispositions and abilities, teach samples of subject matter, and introduce subject-specific critical thinking. Subject-matter departmental and other units will make long-range plans for incorporating critical thinking in varying amounts in subject-matter courses, culminating in a written Senior Thesis/Project involving investigating, taking, and defending a position, which reinforce critical thinking abilities and dispositions and increase subject-matter knowledge. Teaching approaches used in the program are involving and based on the principle, “We learn what we use.” Both summative and formative assessment are employed as appropriate. Coordination and support are extensive. Objections and concerns are discussed, and alternatives, including possible transitions, are considered. An extended review of research supports moving toward CTAC.
Journal Article
Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults
In this randomized trial, the use of video laryngoscopy in critically ill patients undergoing intubation in the ED or ICU resulted in a higher incidence of successful intubation on the first attempt than direct laryngoscopy.
Journal Article
Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults
This randomized, double-blind trial involving critically ill patients compared balanced multielectrolyte solution with saline as fluid therapy in the ICU. There was no evidence that the risk of death or acute kidney injury was lower with the use of BMES than with saline.
Journal Article