Continuous renal replacement therapy (CRRT) in critically ill patients has significant impact on one's ability to provide efficient nutritional therapy. CRRT may help in the prevention of intestinal oedema and the maintenance of the proper function of the gastrointestinal tract by enabling strict control of the fluid balance. It facilitates early introduction of nutrition via the enteral route, as well as allowing for the composition of high-volume feeding mixtures. It is necessary to take into consideration that during CRRT, together with blood purification of toxic substances, nutritive elements are also eliminated to some extent (micro-and macronutrients). In this article, the authors discuss the impact of CRRT on nutritive elements loss, energetic balance and present the principles of adjusting feeding prescriptions to changes implied by CRRT.Anaesthesiology Intensive Therapy 2017, vol. 49, no 4, 309-316 Key words: critical care, nutrition; kidney injury; continuous renal replacement therapy, energy requirements, protein needs Nutritional therapy is one of the basic elements of the multifaceted treatment of patients in intensive care units (ICUs). The Nutrition Day ICU survey, based on a seven-year observation period of nutritional practices in 880 units from 46 countries, has demonstrated that the majority of ICU patients do not receive the recommended amounts of calories and proteins [1]. According to the findings of this survey, as well as of some other studies, an increasing energy-protein deficit is positively correlated with prolonged ICU stay, which in turn increases the risk of infections and death. On the other hand, it should be clearly emphasised that an excessive energy supply may also be associated with complications and increased mortality [1,2]. Adequate tailoring of nutritional therapy is a great challenge; firstly, because the nutritional status of patients on admission to an ICU can differ markedly, ranging from cachexia to morbid obesity while secondly, the critical conditions presented by patients have extremely relevant metabolic implications. Unfortunately, the majority of studies that are the basis for guidelines of nutritional therapy are observational or involve small groups of patients and are therefore characterised by low precision and relatively high changeability over time.Several randomised controlled studies have recently been published which have re-started the discussion on optimal nutritional practices in the ICU setting. One of the issues inadequately described and connected with nutritional therapy in ICU patients, concerns the effects of other elements of the multifaceted treatment of critically ill patients on the efficacy of nutritional interventions. It should be clearly stressed that continuous renal replacement therapy (CRRT) belongs to those interventions which most highly affect the outcomes of nutritional therapy in critically ill pa-310 Anaesthesiol Intensive Ther 2017, vol. 49, no 4, 309-316 tients. Firstly, the use of CRRT facilitates optimal nut...

Standard dosing of caspofungin in critically ill patients has been reported to result in lower drug exposure, which can lead to subtherapeutic AUC0–24/MIC ratios. The aim of the study was to investigate the population pharmacokinetics of caspofungin in a cohort of 30 ICU patients with a suspected invasive fungal infection, with a large proportion of patients requiring extracorporeal therapies including ECMO and CRRT. Caspofungin was administered as empirical antifungal therapy 70 mg i.v. on the first day and 50 mg i.v. on the consecutive days once daily and the concentrations were measured after 3 subsequent doses. Population pharmacokinetic data were analysed by nonlinear mixed-effects modeling. The pharmacokinetics of caspofungin was described by 2-compartment model. A particular drift of individual CL and V1 values with time was discovered and described by including three separate typical values of CL and V1 in the final model. The typical CL values at day one, two and three were 0.563 L/h (6.7 %RSE), 0.737 L/h (6.1 %RSE) and 1.01 L/h (9.1 %RSE), respectively. The change in parameters with time was not explained by any of the recorded covariates. Increasing clearance with subsequent doses was associated with a clinically relevant decrease in caspofungin exposure (>20%). The use of ECMO, CRRT, albumin concentration, and other covariates did not significantly affect caspofungin pharmacokinetics. Additional pharmacokinetic studies are urgently required to assess the possible lack of acquiring steady-state and suboptimal concentrations of the drug in critically ill patients.

Purpose Critically ill old intensive care unit (ICU) patients suffering from Sars-CoV-2 disease (COVID-19) are at increased risk for adverse outcomes. This post hoc analysis investigates the association of the Activities of Daily Living (ADL) with the outcome in this vulnerable patient group. Methods The COVIP study is a prospective international observational study that recruited ICU patients ≥ 70 years admitted with COVID-19 (NCT04321265). Several parameters including ADL (ADL; 0 = disability, 6 = no disability), Clinical Frailty Scale (CFS), SOFA score, intensive care treatment, ICU- and 3-month survival were recorded. A mixed-effects Weibull proportional hazard regression analyses for 3-month mortality adjusted for multiple confounders. Results This pre-specified analysis included 2359 patients with a documented ADL and CFS. Most patients evidenced independence in their daily living before hospital admission (80% with ADL = 6). Patients with no frailty and no disability showed the lowest, patients with frailty (CFS ≥ 5) and disability (ADL < 6) the highest 3-month mortality (52 vs. 78%, p < 0.001). ADL was independently associated with 3-month mortality (ADL as a continuous variable: aHR 0.88 (95% CI 0.82–0.94, p < 0.001). Being “disable” resulted in a significant increased risk for 3-month mortality (aHR 1.53 (95% CI 1.19–1.97, p 0.001) even after adjustment for multiple confounders. Conclusion Baseline Activities of Daily Living (ADL) on admission provides additional information for outcome prediction, although most critically ill old intensive care patients suffering from COVID-19 had no restriction in their ADL prior to ICU admission. Combining frailty and disability identifies a subgroup with particularly high mortality. Trial registration number: NCT04321265. Graphical Abstract

BACKGROUND Several studies have shown an analgesic efficacy of a transversus abdominis plane block (TAPB) in reducing opioid requirements during and after cadaveric renal transplantation surgery, but the effect of a quadratus lumborum block (QLB) in this type of surgery is unclear. OBJECTIVES The main objective of this prospective, randomised, double-centre clinical study was to compare the analgesic efficacy of a one-sided lateral approach TAPB with a unilateral QLB type 2 in cadaveric renal transplantation surgery. DESIGN Randomised, single-blinded trial. SETTING Two University-affiliated tertiary care hospitals between April 2016 and May 2017. PATIENTS A total of 101 patients aged more than 18 years, scheduled for cadaveric renal transplantation. INTERVENTIONS On receiving ethical board approval and individual informed consent, consecutive patients were allocated randomly to receive either an ultrasound-guided single-shot lateral TAPB or an ultrasound-guided single-shot QLB type 2 on the surgical side using 20 ml of bupivacaine 0.25% with adrenaline after a standardised induction of general anaesthesia. All patients on surgical completion and recovery from general anaesthesia were admitted to the postanaesthesia care unit for 24 h. They received standardised intravenous patient-controlled analgesia with fentanyl, and their pain scores were noted at regular intervals. MAIN OUTCOME MEASURES The primary endpoint was total cumulative fentanyl dose used per kg body mass in the first 24 h after surgery. Secondary outcomes were the need to start a continuous infusion of fentanyl in addition to patient-controlled analgesia boluses during the stay in post-anaesthesia care unit, postoperative pain severity measured using a numerical rating scale, patient satisfaction with analgesic treatment, evidence of postoperative nausea and vomiting, pruritus and sedation level. RESULTS The 49 patients allocated to the QLB type 2 group used significantly less fentanyl per kg in the first 24 h after surgery than the 52 patients who received a TAPB (median [IQR] 4.2 [2.3 to 8.0] μg kg−1 versus 6.7 [3.5 to 10.7] μg kg−1, P = 0.042). No statistically significant differences were noted in the secondary endpoints within the study, including the frequency of adverse effects of opioids. CONCLUSION The reduction of fentanyl consumption in the first 24 h after renal transplantation with no difference in pain intensity and patient satisfaction shows a beneficial effect of one-sided QLB type 2 over a one-sided TAPB in regards to postoperative analgesia. However, the reduction in opioid consumption did not affect the frequency of opioid-related adverse effects. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02783586.

Septic shock, similar to other types of circulatory shock, is characterised by peripheral hypoperfusion and, consequently, inadequate tissue oxygen deli very. It is commonly believed that intravenous fluid infusion improves organ perfusion and reverses cel lular dysoxia. This belief might be valid in the early phase of septic shock, and some earlier studies [1] and international recommendations (Surviving Sepsis Campaign) [2] support this view. The physio logical rationale behind fluid bolus administration is that it causes intravascular volume expansion. According to the FrankStarling principle, increased left ventricular enddiastolic volume (i.e., preload) increases stroke volume (SV), resulting in improved organ perfusion. This mechanism works until the optimal preload is achieved. However, the patho physiology of septic shock is complex and compris es both distributive and cardiogenic components. At the peripheral level, the inflammatory process in sepsis damages the endothelial glycocalyx [3] and