Patients with late initiation of total parenteral nutrition (TPN) were more likely to be discharged alive from the ICU within eight days despite having increased risk of hypoglycemia and more elevation of inflammatory markers. They had shorter ICU and hospital stays, fewer days on the ventilator, fewer infectious complications, were less likely to develop renal failure, and had lower overall costs. The unblinded management of these patients raises concern in interpreting infectious outcomes because study investigators could have been biased to look for infection more often in the early initiation group.
Bottom line: In ICU patients at risk for malnutrition, delaying initiation of TPN to supplement enteral feeding shortens ICU stay and reduces infectious complications when compared with early initiation of TPN.
Citation: Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-17.
Intrapleural Instillation of Combined DNase and t-PA Improve Outcomes in Patients with Empyema
Clinical question: Does the intrapleural administration of a fibrinolytic, a recombinant DNase, or a combination of the two improve outcomes in patients with pleural infections compared with placebo?
Background: Pleural-based infections confer high morbidity and mortality, especially in the one-third of cases in which chest tube drainage fails. Observational data suggest intrapleural administration of fibrinolytics can improve drainage; however, a large randomized trial (MIST1) failed to show improvement with streptokinase.
Study design: Randomized, double-blind, double-dummy, factorial, multicenter trial.
Setting: University hospitals in the U.K.
Synopsis: A total of 193 patients with clinical evidence of an infection as well as laboratory evidence of pleural infection were randomized in factorial design to placebo, DNase alone, t-PA alone, and DNase plus t-PA as a twice-daily, hourlong instillation into the pleural space on hospital days 1 through 3. The combination group had improvements in the size of the pleural effusion compared with placebo, the primary endpoint. This group also was less likely to be referred for surgery, had shorter hospital stays, had less fever, and had lower inflammatory markers by hospital Day 7. Neither of the single-agent groups were better than placebo. The confidence intervals for all outcomes besides radiographic size of the effusion were large, as the trial had limited power for secondary endpoints.
Bottom line: In patients with empyema, the addition of twice-daily instillations of DNase and tPA can improve drainage and decrease risk of treatment failure when combined with chest tube drainage and antibiotics.
Citation: Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365:518-526.
Smoothing Admissions over the Week Improves Patient Flow
Clinical question: What is the difference between weekday and weekend hospital occupancy, and what might the effect be of redistributing, or “smoothing,” elective admissions across the week?
Background: Efforts to improve patient flow have largely focused on reducing the average length of stay (ALOS). As the ALOS decreases, though, further reductions have limited yield in improving patient flow and could occur at the expense of patient safety. Smoothing admissions is a recognized but underutilized tool to address patient flow and hospital overcrowding.
Study design: Retrospective cohort.
Setting: Thirty-nine freestanding, tertiary-care children’s hospitals in the U.S.
Synopsis: Hospital occupancy ranged from 70.9% to 108.1% for weekdays, and from 65.7% to 94.4% on weekends. The mean difference between weekday and weekend occupancy was 8.2%. Using a mathematical model to redistribute admissions from peak days to nonpeak days (within a one-week time frame), the investigators found that percent occupancy on average dropped by 6.6%—the same number of patients over the same time interval, but with lower average occupancy. And, while not projected by these authors, the correlate of lower average occupancy would be reduced waits and delays for admission and within-hospital services. Only 2.6%, or about 7.5 admissions per week per hospital, would need to be rescheduled in order to realize this gain.