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Biomedical subjects

D K Heyland

Publications and source records attributed to D K Heyland.

At least 37 records · Page 2Linked to original sources
PubMed1999

The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group.

To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, we conducted a prospective, matched cohort study. Patients expected to be ventilated for > 48 h were prospectively followed for the development of VAP. To determine the excess ICU stay and mortality attributable to VAP, we matched patients with VAP to patients who did not develop clinically suspected pneumonia. We also conducted sensitivity analyses to examine the effect of different populations, onset of pneumonia, diagnostic criteria, causative organisms, and adequacy of empiric treatment on the outcome of VAP. One hundred and seventy-seven patients developed VAP. As compared with matched patients who did not develop VAP, patients with VAP stayed in the ICU for 4.3 d (95% confidence interval [CI]: 1.5 to 7. 0 d) longer and had a trend toward an increase in risk of death (absolute risk increase: 5.8%; 95% CI: -2.4 to 14.0 d; relative risk (RR) increase: 32.3%; 95% CI: -20.6 to 85.1%). The attributable ICU length of stay was longer for medical than for surgical patients (6. 5 versus 0.7 d, p < 0.004), and for patients infected with "high risk" organisms as compared with "low risk" organisms (9.1 d versus 2.9 d). The attributable mortality was higher for medical patients than for surgical patients (RR increase of 65% versus -27.3%, p = 0. 04). Results were similar for three different VAP diagnostic criteria. We conclude that VAP prolongs ICU length of stay and may increase the risk of death in critically ill patients. The attributable risk of VAP appears to vary with patient population and infecting organism.

Critical Illness↗
PubMed1999

The clinical utility of invasive diagnostic techniques in the setting of ventilator-associated pneumonia. Canadian Critical Care Trials Group.

OBJECTIVE: To evaluate the clinical utility of bronchoscopy with protected brush catheter (PBC) and BAL for patients with ventilator-associated pneumonia (VAP). DESIGN: Prospective cohort study. SETTING: Ten tertiary care ICUs in Canada. PATIENTS: Ninety-two mechanically ventilated patients with a clinical suspicion of VAP who underwent bronchoscopy were compared with 49 patients with a clinical suspicion of pneumonia who did not. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: We compared antibiotic use, duration of mechanical ventilation, ICU stay, and mortality. In addition, for patients who received bronchoscopy, we administered a questionnaire (before and after bronchoscopy) to evaluate the effect of PBC or BAL on (1) physician perception of the probability of VAP, (2) physician confidence in the diagnosis of VAP, and (3) changes to antibiotic management. After bronchoscopy results became available, from the physician's perspective, the diagnosis of VAP was deemed much less likely (p < 0.001), confidence in the diagnosis increased (p = 0.03), and level of comfort with the management plan increased (p = 0.02). Following the results of invasive diagnostic tests, in the group that underwent bronchoscopy, patients were receiving fewer antibiotics (31/92 vs 9/49, p = 0.05) and more patients had treatment with all their antibiotics discontinued (18/92 vs 3/49, p = 0.04) compared with the group that did not undergo bronchoscopy. Duration of mechanical ventilation and ICU stay were similar between the two groups, but mortality was lower in the group that underwent bronchoscopy with PBC or BAL (18.5% vs 34.7%, p = 0.03). CONCLUSIONS: Invasive diagnostic testing may increase physician confidence in the diagnosis and management of VAP and allows for greater ability to limit or discontinue antibiotic treatment. Whether performing PBC or BAL affects clinically important outcomes requires further study.

Anti-Bacterial Agents↗
PubMed1999

How advance directives affect hospital resource use. Systematic review of the literature.

OBJECTIVE: To assess whether advance directives influence resource use by hospitalized patients. DATA SOURCES: A systematic search of computerized medical databases, reference lists from relevant articles, and personal files was conducted to identify studies examining the association between advance directives and resource use. STUDY SELECTION: Primary studies assessing the effect of advance directives on hospital resource use were selected if they had a clear quantitative measure of hospital resource use, hospitalized patients as a study population, a control group for comparison, and a description of the advance directive being studied. Data on the following topics were abstracted from studies meeting inclusion criteria: study methods and design, resource use, source of financial data, description of advance directive, population size and composition, length of assessment. SYNTHESIS: Six studies met inclusion criteria. Three retrospective studies showed significant reductions in resource use associated with documentation of advance directives while three prospective studies (two randomized, one not randomized) showed no association between advance directives and reduced resource use. Studies were limited to narrowly defined patient populations in US tertiary care hospitals. CONCLUSIONS: Little evidence supports the hypothesis that advance directives reduce resource use by hospitalized patients. Some retrospective studies have shown savings, but their conclusions are weakened by shortcomings in study design. Prospective trials, which have better experimental methods, have demonstrated no evidence of cost savings with the use of advance directives.

Advance Directives↗
PubMed1998

Total parenteral nutrition in the critically ill patient: a meta-analysis.

CONTEXT: Nutritional support has become a standard of care for hospitalized patients, but whether total parenteral nutrition (TPN) affects morbidity and mortality is unclear. OBJECTIVE: To examine the relationship between TPN and complication and mortality rates in critically ill patients. DATA SOURCES: Computerized search of published research on MEDLINE from 1980 to 1998, personal files, and review of relevant reference lists. STUDY SELECTION: We reviewed 210 titles, abstracts, and papers. Primary studies were included if they were randomized clinical trials of critically ill or surgical patients that evaluated the effect of TPN (compared with standard care) on complication and mortality rates. We excluded studies comparing TPN with enteral nutrition. DATA EXTRACTION: Relevant data were abstracted on the methodology and outcomes of primary studies. Data were abstracted in duplicate, independently. DATA SYNTHESIS: There were 26 randomized trials of 2211 patients comparing the use of TPN with standard care (usual oral diet plus intravenous dextrose) in surgical and critically ill patients. When the results of these trials were aggregated, TPN had no effect on mortality (risk ratio [RR], 1.03; 95% confidence interval [CI], 0.81-1.31). Patients who received TPN tended to have a lower complication rate, but this result was not statistically significant (RR, 0.84; 95% CI, 0.64-1.09). We examined several a priori hypotheses and found that studies including only malnourished patients were associated with lower complication rates but no difference in mortality when compared with studies of nonmalnourished patients. Studies published since 1989 and studies with a higher methods score showed no treatment effect, while studies published in 1988 or before and studies with a lower methods score demonstrated a significant treatment effect. Complication rates were lower in studies that did not use lipids; however, there was no difference in mortality rates between studies that did not use lipids and those studies that did. Studies limited to critically ill patients demonstrated a significant increase in complication and mortality rates compared with studies of surgical patients. CONCLUSIONS: Total parenteral nutrition does not influence the overall mortality rate of surgical or critically ill patients. It may reduce the complication rate, especially in malnourished patients, but study results are influenced by patient population, use of lipids, methodological quality, and year of publication.

Critical Care↗
PubMed1998

Nutritional support in the critically ill patients. A critical review of the evidence.

Providing nutritional support has become a standard component of managing critically ill patients. While many studies have documented that providing nutritional support can change nutritional outcomes (e.g., amino acid profile, weight gain, nitrogen balance), data are lacking that demonstrate that nutrition actually influences clinically importance endpoints. This article systematically reviews and critically appraises the literature, examining the relationship between nutritional support and infectious morbidity and mortality in the critically ill patient. In addition, evidence-based recommendations are made.

Adult↗
PubMed1998

Frequency and methodologic rigor of quality-of-life assessments in the critical care literature.

OBJECTIVES: To present a framework for describing/measuring quality of life (QOL) and health-related quality of life (HRQL), and to assess the frequency and methodologic rigor of QOL studies in the adult critical care literature. DATA SOURCES: Computerized bibliographic search of published research, manual search of key intensive care unit (ICU) journals, and citation review of relevant articles. STUDY SELECTION: We manually searched Critical Care Medicine, American Journal of Respiratory and Critical Care Medicine, and Intensive Care Medicine for the period January 1992 to July 1995 to assess the frequency of published QOL studies. Combined with a computerized bibliographic search, we found 64 studies that met our criteria that reported on patient-related outcomes (other than mortality) after hospital discharge. DATA EXTRACTION: We abstracted data on the nature of each study, the instruments used to measure QOL, and the methodologic rigor of the QOL assessments. We evaluated each study using criteria we developed to assess the validity of HRQL measurements. MEASUREMENTS AND MAIN RESULTS: In our manual search, we found 1,073 articles relevant to the practice of adult critical care. Of these, 19 (1.7%)/1073 included QOL measurements. Combined with our comprehensive search strategy, we found 64 papers that evaluated QOL in ICU patients. These papers dealt primarily with issues of: prognosis (32 [50%]), resource allocation (23 [36%]), and clinical prediction (9 [14%]). We found no randomized trials that included post-ICU QOL as an outcome. With respect to the validity of the HRQL assessments, 63/64 (98%) studies evaluated aspects of patients' lives that we considered important. Thirty-three (52%) studies were limited in scope to specific aspects of HRQL, and 31 (48%) studies covered broad areas of HRQL. In these 64 studies, there were 108 different instruments used. The reliability and validity of the instruments used were reported in 7 (6%) and 15 (14%) cases, respectively. For 81 (75%) instruments, the investigators either explained the results or used informative, qualitative descriptors whose interpretation was self-evident. Overall, three (5%) of the included studies met all four methodologic criteria to assess the validity of HRQL assessments. CONCLUSIONS: QOL assessments occur infrequently in the ICU literature and are of limited methodologic quality. More studies using valid and reliable instruments are necessary to document the long-term QOL of critically ill patients, especially those at risk of a "poor" outcome.

Adult↗
PubMed1998

How to use a review article: prophylactic endoscopic sclerotherapy for esophageal varices. Evidence Based Critical Care Medicine Group.

OBJECTIVE: To assess the validity of a meta-analysis about sclerotherapy for the primary prevention of bleeding from esophageal varices, to interpret the results, and discuss whether they apply in practice. DATA SOURCES: Critical appraisal techniques for systematic reviews. DATA EXTRACTION: Systematic reviews are distinct from narrative reviews in that they answer specific clinical questions, and have explicit and reproducible methods for searching, selecting, and appraising the primary studies, to create the most valid synthesis of the evidence. DATA SYNTHESIS: Meta-analyses are systematic reviews containing a critical appraisal and statistical summary of individual study results and their confidence limits, whereas qualitative systematic reviews provide a narrative executive summary of study results. CONCLUSIONS: High-quality systematic reviews are being used increasingly to guide practice, strengthening the link between research results and improved health outcomes. Understanding their strengths and limitations helps us to use them appropriately in practice.

Critical Care↗
PubMed1998

Is it 'worthwhile' to continue treating patients with a prolonged stay (>14 days) in the ICU? An economic evaluation.

OBJECTIVE: To compare the cost and consequences of a policy of continuing to care for patients with a prolonged stay in the ICU with a proposed policy of withdrawing support. DESIGN: Economic evaluation using data derived from a prospective cohort study. SETTING: Adult medical/surgical ICU in a tertiary care hospital. PATIENTS: Consecutive patients admitted to the ICU. INTERVENTION: None. MAIN OUTCOME MEASURES: We performed a cost-accounting analysis on each patient in the ICU and followed up patients until 12 months after admission to ICU and assessed components of quality of life in survivors. RESULTS: During the study period, 690 patients were admitted to the ICU. Only 61 (9%) patients remained in the ICU for > 14 days. For this group, the mean length of stay in the ICU was 24.5 (+/-11.7) days and duration in hospital was 57.9 (+/-56.9) days. At 12 months, 27 (44%) were alive. Overall, the mean quality of life score at 12 months did not differ between patients with a short or prolonged stay in the ICU. The average ICU cost per day per patient was $1,565 (Canadian) resulting in a total cost for the whole cohort of Can $1,917,382. Over the same time period, 58 patients had life support withdrawn. On average, patients survived another day in the ICU, 2 more days in hospital, and all patients ultimately died. When treatment was discontinued, the costs of treating this cohort was Can $156,465. The incremental cost-effectiveness ratio is Can $65,219 per life saved or Can $4,350 per life-year saved. CONCLUSIONS: A considerable proportion of patients with a prolonged length of stay in the ICU survive their critical illness. Furthermore, their long-term quality of life seems reasonable. Our data suggest that continuing treatment for patients with a prolonged ICU stay may represent an efficient use of hospital resources and should be considered in the context of local budgets.

Adult↗
PubMed1997

How to use an article on therapy or prevention: pneumonia prevention using subglottic secretion drainage.

Evidence based critical care medicine involves integrating clinical experience, expertise, and patient preferences with explicit, systematic, and judicious use of current best evidence in making medical decisions. Published evidence has many sources: research from the basic sciences of medicine, and from patient-centered clinical research on the accuracy of diagnostic tests, the power of prognostic markers, and the effectiveness and safety of preventive, therapeutic, rehabilitative, and palliative interventions. When critically appraising a clinical article for potential use in intensive care unit (ICU) practice, the first question we ask ourselves is: Is this study valid? If examination of the study methods reveals that the design is rigorous, we can turn to the two other key questions: What are the results? and, Will the results help me care for my patients? This approach may aid in the interpretation of an article on therapy or prevention; in it we discuss a strategy designed to prevent ventilator associated pneumonia in critically ill patients.

Critical Care↗
PubMed1996

Impaired gastric emptying in mechanically ventilated, critically ill patients.

OBJECTIVE: To measure gastric emptying in critically ill patients using an acetaminophen absorption model and determine which variables are associated with impaired gastric emptying. DESIGN: A prospective, cohort study. SETTING: A medical/surgical ICU at a tertiary care hospital: Hamilton General Hospital, Hamilton, Ontario. PATIENTS AND PARTICIPANTS: We recruited 72 mechanically ventilated patients expected to remain in the ICU for more than 48 h. Our results were compared to those in healthy volunteers. INTERVENTION: Within 48 h of admission to the ICU, 1.6 g acetaminophen suspension were administered via a nasogastric tube into the stomach. Blood samples were drawn a t = 0, 30, 60, 90, and 120 min for measurement of plasma acetaminophen levels determined by the enzymatic degradation method. MEASUREMENTS AND RESULTS: Maximal concentration of acetaminophen was 94.1 (75.3) mumol/l compared to 208.4 (33.1) mumol/l in a control population (p < 0.0001). The time to reach the maximal concentration was 105 min (60-180) compared to 30 min (15-90) in controls (p < 0.0001). The area under the time-acetaminophen concentration curve t = 120 was 9301 (7343) mumol/min per l compared to 11644 (1336) mumol/min per l in the controls (p = 0.28). The variables associated with delayed gastric emptying were age, sex and use of opioids for analgesia and sedation. CONCLUSIONS: Gastric emptying is delayed in critically ill patients. The important consequences of this phenomenon include intolerance to enteral nutrition and gastric colonization. Strategies to minimize the use of narcotics may improve gastric emptying. Studies to examine the effect of gastrointestinal prokinetic agents on gastric emptying are needed.

Acetaminophen↗
PubMed1996

Maximizing oxygen delivery in critically ill patients: a methodologic appraisal of the evidence.

OBJECTIVE: To systemically review the effect of interventions designed to achieve supraphysiologic values of cardiac index, oxygen delivery (DO2), and oxygen consumption (VO2) in critically ill patients. DATA SOURCES: Computerized bibliographic search of published research, citation review of relevant articles, and contact with primary investigators. STUDY SELECTION: We included all randomized clinical trials of adult intensive care unit (ICU) patients that evaluated interventions (fluids, inotropes, and vasoactive drugs) designed to achieve supraphysiologic values of cardiac index, DO2, and/or VO2. Independent review of 64 articles identified seven relevant studies of 1,016 patients. DATA EXTRACTION: We abstracted data on the population, interventions, outcomes, and methodologic quality of the studies by duplicate independent review. Agreement was high (weighed kappa 0.73); differences were resolved by consensus. DATA SYNTHESIS: Targeting therapy to achieve supraphysiologic end points in critically ill patients is associated with a nonstatistically significant trend toward decreased mortality rates (relative risk 0.86, 95% confidence intervals 0.62 to 1.20). For the two studies in which supraphysiologic goals were initiated preoperatively, the relative risk was 0.20 (95% confidence intervals 0.07 to 0.55). This value differed significantly from the combined estimate of the remaining studies, in which the intervention was started after ICU admission (relative risk 0.98, 95% confidence intervals 0.79 to 1.22; p<.01). However, there are several methodologic problems with the primary studies. In no trials were caregivers or outcome assessors blinded to treatment allocation. Only three of seven trials analyzed patients according to the group to which they were allocated. None adequately controlled for cointerventions, and there was considerable crossover between groups (patients in the control group achieved the goals of the intervention group and vice versa). CONCLUSIONS: Interventions designed to achieve supraphysiologic goals of cardiac index, DO2, and VO2 did not significantly reduce mortality rates in all critically ill patients. However, there may be a benefit in those patients in which the therapy is initiated preoperatively. Methodologic limitations weaken the inferences that can be drawn from these studies and preclude any evidence-based clinical recommendations.

Adult↗
PubMed1996

Economic evaluations in the critical care literature: do they help us improve the efficiency of our unit?

OBJECTIVE: To determine the extent to which economic evaluations published in the critical care literature provide information that can help us to improve the efficiency of our unit. DATA SOURCES: We searched computerized bibliographic databases and manually searched key critical care journals to retrieve all economic evaluations. STUDY SELECTION: We included economic evaluations that dealt with clinical problems relevant to the practice of adult critical care and that compared competing healthcare interventions. DATA ABSTRACTION: Included articles were further evaluated using criteria for minimal methodologic soundness, adopted from the literature, and criteria that we developed to assess the generalizability of results to our clinical setting. DATA SYNTHESIS: We screened 4,167 papers manually and > 450 abstracts and titles in our computer search. One hundred fifty-one papers were retrieved for further evaluation; 29 papers met our inclusion criteria. Of these 29 papers, only 14 (48%) adequately described competing healthcare interventions, 17 (59%) provided sufficient evidence of clinical efficacy, six (21%) identified, measured, and valuated costs appropriately, and three (10%) performed a sensitivity analysis. None of the papers met all four of these criteria for a minimum level of methodologic soundness. Four (14%) of 29 studies which adequately dealt with issues of cost and efficacy were evaluated using our generalizability criteria. Different costing methods precluded the application of the results of three of the four studies to our intensive care unit. CONCLUSIONS: In the critical care literature, very little useful economic information exists to help decision-makers maximize efficiency in their own setting.

Adult↗
PubMed1996

Cisapride improves gastric emptying in mechanically ventilated, critically ill patients. A randomized, double-blind trial.

We conducted a randomized, double-blind, placebo-controlled trial in mechanically ventilated intensive care unit (ICU) patients to evaluate the effect of cisapride on gastric emptying using an acetaminophen absorption model. We enrolled 72 patients expected to remain in the ICU for more than 48 h; 39% were female; the average age was 54.0 +/- 19.1 yr; 47% were postoperative, 83% were receiving narcotics, and the mean simplified acute physiology score (SAPS) was 9.5 +/- 3.0. Within 72 h of admission to ICU, 1.6 g of acetaminophen suspension was administered via a nasogastric tube into the stomach (Day 1). Blood samples were drawn at baseline, 30, 60, 90, 120, and 180 min for measurement of plasma acetaminophen levels. The following morning (Day 2), patients were randomized to receive 20 mg of cisapride or placebo and gastric emptying was again assessed. The difference (Day 2-Day 1) in the maximal plasma concentration was 49.1 mumol/L in the cisapride groups compared with 12.3 mumol/L in the placebo group (p = 0.005) and the time to reach maximal concentration was significantly shorter in the cisapride group (-40.8 min versus -4.2 min, p = 0.02). The difference in area under the time-acetaminophen concentration curve was also greater in the patients receiving cisapride (5,534 versus 2,832, p = 0.09). We conclude that cisapride enhances gastric emptying in critically ill patients. Studies to examine the effect of cisapride on tolerance to enteral nutrition, infectious morbidity, and other clinically important outcomes are warranted.

Acetaminophen↗
PubMed1995

Corticosteroid treatment for sepsis: a critical appraisal and meta-analysis of the literature.

OBJECTIVE: To determine the effect of corticosteroid therapy on morbidity and mortality in patients with sepsis. DATA SOURCES: We searched for published and unpublished research using MEDLINE, EMBASE, and the Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, personal files, and contact with primary investigators. STUDY SELECTION: From a pool of 124 potentially relevant articles, duplicate independent review identified nine relevant, randomized, controlled trials of corticosteroid therapy in sepsis and septic shock among critically ill adults. DATA EXTRACTION: In duplicate, independently, we abstracted key data on population, intervention, outcome, and methodologic quality of the randomized controlled trials. DATA SYNTHESIS: Corticosteroids appear to increase mortality in patients with overwhelming infection (relative risk 1.13, 95% confidence interval 0.99 to 1.29), and have no beneficial effect in the subgroup of patients with septic shock (relative risk 1.07, 95% confidence interval 0.91 to 1.26). Studies with the highest methodologic quality scores also suggest a trend toward increased mortality overall (relative risk 1.10, 95% confidence interval 0.94 to 1.29). A similar trend was observed for patients with septic shock (relative risk 1.12, 95% confidence interval 0.95 to 1.32). No difference in secondary infection rates was demonstrated in corticosteroid-treated patients with sepsis or septic shock. However, there was a trend toward increased mortality from secondary infections in patients receiving corticosteroids (relative risk 1.70, 95% confidence interval 0.70 to 4.12). The occurrence rate of gastrointestinal bleeding was increased slightly in the treatment group (relative risk 1.17, 95% confidence interval 0.79 to 1.73). CONCLUSIONS: Current evidence provides no support for the use of corticosteroids in patients with sepsis or septic shock, and suggests that their use may be harmful. These trials underscore the need for future methodologically rigorous trials evaluating new immune-modulating therapies in well-defined critically ill patients with overwhelming infection.

Adrenal Cortex Hormones↗
PubMed1994

Does the formulation of enteral feeding products influence infectious morbidity and mortality rates in the critically ill patients? A critical review of the evidence.

OBJECTIVE: To examine the relationship between the formulation of enteral nutrition and nosocomial infection in critical illness. DATA SOURCES: Computerized search of published research and reference list review. STUDY SELECTION: Review of 151 citations. Included are 31 primary studies in which the authors described the formulation of enteral nutrition and its effect on infectious morbidity and mortality rates in critically ill humans or animals. DATA EXTRACTION: Abstraction of the methods of primary studies and the impact of the composition of enteral nutrition on infectious morbidity and mortality rates. DATA SYNTHESIS: There is no evidence that the addition of branch-chain amino acids or nucleotides to enteral nutrition reduces infectious morbidity in animals or humans. Supplementation with fish oil, arginine, or glutamine has a variable impact on survival in animal models; there are no clinical trials in critically ill patients that demonstrate reduced infectious morbidity or mortality rates. Some animal studies suggest that intestinal overgrowth and bacterial translocation may be related to the type of fiber used, or elemental or polymeric formulas. Preliminary evidence suggests that Modular Tube Feeds (an enteral formula developed at the Shriner's Burn Institute, Cincinnati, OH), and a commercially available enteral formula (enhanced with omega-3-fatty acids, arginine, and yeast RNA; Impact, Sandoz Nutrition, Minneapolis, MN) may result in decreased infections in burn and postoperative cancer patients, respectively, but not in critically ill patients. Acidification of enteral feeding results in decreased bacterial colonization of the stomach in critically ill patients. CONCLUSIONS: Insufficient experimental data exist to permit conclusions that enteral nutrition formulations or supplements reduce infectious morbidity and mortality rates, but results are promising enough to warrant further research.

Amino Acids, Branched-Chain↗
PubMed1993

Enteral nutrition in the critically ill patient: a critical review of the evidence.

OBJECTIVE: To examine the relationship between enteral nutrition (EN) and infection in the critically ill. SETTING: Computerized search of published research and review of relevant reference lists. STUDY SELECTION: 151 citations were reviewed and 39 articles met selection criteria. Primary studies were included if they evaluated EN in critically ill humans and its effect on infectious morbidity and mortality. MEASUREMENTS AND RESULTS: Relevant data were abstracted on the timing and impact of EN on morbidity, the optimal route of administration, composition and pH of EN, and bacterial contamination of EN. The evidence from human studies that EN, particularly early EN, results in reduced septic morbidity as compared to parenteral nutrition is limited to small, unblinded studies with non-rigorous definitions of pneumonia. There is no evidence to support a preference of feeding into the stomach versus the small bowel. The addition of fish oil, arginine, glutamine and fiber to enteral feeds has a variable impact on survival in animal models; there are no trials in critically ill patients that demonstrate a reduction in infectious morbidity and mortality. Acidification of enteral nutrition results in decreased bacterial colonization of the stomach in critically ill patients. Bacterial contamination of enteral nutrition is an important source of infection. CONCLUSIONS: Evidence from experimental data in critically ill patients suggests that enteral nutrition may have a favourable impact on gastrointestinal immunological function and infectious morbidity.

Critical Illness↗