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About 14% of critically ill patients receiving electrolyte-balanced crystalloids either developed kidney failure, needed kidney-replacement therapy or died compared with 15% receiving normal saline. This small but statistically significant benefit was only apparent when combining outcomes; there was no difference between fluids for the three individual outcomes analysed separately.

A solution of 0.9% sodium chloride (normal saline) is the most commonly used intravenous (IV) fluid, but it can cause biochemical imbalance. Alternative crystalloids like Ringer's lactate or Hartmann’s solution contain an electrolyte composition closer to normal blood fluid and are often seen as preferable.

This US trial compared 30-day outcomes for over 15,000 critical patients randomised to either fluid type. The difference in outcomes between fluid types was very small, but there is a difference in cost.

The small benefit perhaps argues against routine use of balanced crystalloids in all patients. Though what is most important is that the fluid and electrolyte needs of the individual are recognised and met.

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Checklist for ABCDE Protocol

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Bedside Treatments for ABCDE Protocol

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CRD summary
Tight glucose control does not significantly reduce hospital mortality among critically ill adult patients, but it does increase the risk of hypoglycaemia. The review was generally well conducted and these conclusions seem likely to be reliable.
Authors' objectives
To evaluate the benefits and risks of tight glucose control compared with usual care in critically ill adults.

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It's a decision being made thousands of times over inside hospitals all around the country: is it time to place a patient struggling to breathe on a ventilator? For all of the attention ventilators have received during the COVID-19 pandemic, deciding when to place patients on them—and when to take them off—is complex. Michigan Medicine researchers have been investigating best practices for mechanical ventilation for years, never knowing how applicable their work would become.

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Clinical and cost effectiveness of diagnostic strategies incorporating Beta-D-glucan (BDG) tests to reduce unnecessary use of empirical antifungal therapies for invasive Candida infection in the critical care setting

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Background

Patients admitted to intensive care and on mechanical ventilation, are administered sedative and analgesic drugs to improve both their comfort and interaction with the ventilator. Optimizing sedation practice may reduce mortality, improve patient comfort and reduce cost. Current practice is to use scales or scores to assess depth of sedation based on clinical criteria such as consciousness, understanding and response to commands. However these are perceived as subjective assessment tools. Bispectral index (BIS) monitors, which are based on the processing of electroencephalographic signals, may overcome the restraints of the sedation scales and provide a more reliable and consistent guidance for the titration of sedation depth.

The benefits of BIS monitoring of patients under general anaesthesia for surgical procedures have already been confirmed by another Cochrane review. By undertaking a well‐conducted systematic review our aim was to find out if BIS monitoring improves outcomes in mechanically ventilated adult intensive care unit (ICU) patients.
Objectives

To assess the effects of BIS monitoring compared with clinical sedation assessment on ICU length of stay (LOS), duration of mechanical ventilation, any cause mortality, risk of ventilator‐associated pneumonia (VAP), risk of adverse events (e.g. self‐extubation, unplanned disconnection of indwelling catheters), hospital LOS, amount of sedative agents used, cost, longer‐term functional outcomes and quality of life as reported by authors for mechanically ventilated adults in the ICU.
Search methods

We searched CENTRAL, MEDLINE, Embase, CINAHL, ProQuest, OpenGrey and SciSearch up to May 2017 and checked references citation searching and contacted study authors to identify additional studies. We searched trial registries, which included clinicaltrials.gov and controlled‐trials.com.
Selection criteria

We included all randomized controlled trials comparing BIS versus clinical assessment (CA) for the management of sedation in mechanically ventilated critically ill adults.
Data collection and analysis

We used Cochrane's standard methodological procedures. We undertook analysis using Revman 5.3 software.
Main results

We identified 4245 possible studies from the initial search. Of those studies, four studies (256 participants) met the inclusion criteria. One more study is awaiting classification. Studies were, conducted in single‐centre surgical and mixed medical‐surgical ICUs. BIS monitor was used to assess the level of sedation in the intervention arm in all the studies. In the control arm, the sedation assessment tools for CA included the Sedation‐Agitation Scale (SAS), Ramsay Sedation Scale (RSS) or subjective CA utilizing traditional clinical signs (heart rate, blood pressure, conscious level and pupillary size). Only one study was classified as low risk of bias, the other three studies were classified as high risk.

There was no evidence of a difference in one study (N = 50) that measured ICU LOS (Median (Interquartile Range IQR) 8 (4 to 14) in the CA group; 12 (6 to 18) in the BIS group; low‐quality evidence).There was little or no effect on the duration of mechanical ventilation (MD ‐0.02 days (95% CI ‐0.13 to 0.09; 2 studies; N = 155; I2 = 0%; low‐quality evidence)). Adverse events were reported in one study (N = 105) and the effects on restlessness after suction, endotracheal tube resistance, pain tolerance during sedation or delirium after extubation were uncertain due to very low‐quality evidence. Clinically relevant adverse events such as self‐extubation were not reported in any study. Three studies reported the amount of sedative agents used. We could not measure combined difference in the amount of sedative agents used because of different sedation protocols and sedative agents used in the studies. GRADE quality of evidence was very low. No study reported other secondary outcomes of interest for the review.
Authors' conclusions

We found insufficient evidence about the effects of BIS monitoring for sedation in critically ill mechanically ventilated adults on clinical outcomes or resource utilization. The findings are uncertain due to the low‐ and very low‐quality evidence derived from a limited number of studies.

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We will break our conversation about preventing Post Intensive Care Syndrome into two parts. This month in Part I, we will focus on steps that the health care team will take to prevent PICS. Next month in Part II, we will focus on preventative steps that loved ones can take.

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We are going to discuss Post Intensive Care Syndrome and Prevention Part II - what loved ones can do to help prevent PICS.

It is not uncommon for loved ones to feel overwhelmed when in the intensive care unit. The ICU is a very unfamiliar and scary environment for most people, and caring for your critically ill loved one can seem like too much at times. However, the physical presence through voice and touch that a loved one can provide can be as therapeutically beneficial as many of the interventions provided by the medical team.

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The emotional aftermath of critical illness/injury is something that often catches people by surprise but can have a significant impact on daily life. People who have been critically ill/injured often describe difficulty with anxiety, depression, and symptoms of post-traumatic stress disorder such as nightmares, flashbacks, and insomnia.

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Following critical illness, it is not uncommon for one to experience new or worsened physical limitations or difficulties. This can be due to the critical illness/injury itself, prolonged time spent in bed with limited physical activity, or preexisting physical challenges that worsen following hospitalization. Of all of the aspects of Post Intensive Care Syndrome (body, mind, and emotions), the physical changes are the most easily recognized and are therefore more readily addressed.

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Short term memory loss. Word finding difficulty. Trouble concentrating. Difficulty with work or school. These are some of the symptoms that patients with Post Intensive Care Syndrome describe having following critical illness/injury. These symptoms can vary on the spectrum of severity, but for those who suffer from the cognitive effects of PICS even subtle difficulties can be life-changing. Loss of work, poor academic performance, and disrupted personal lives are unfortunately a reality for many people affected by PICS.