J Pediatr Intensive Care 2015; 04(04): 194-203
DOI: 10.1055/s-0035-1563546
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Optimal Nutrition for Acute Rehabilitation in the PICU

Heather E. Skillman
1   Department of Clinical Nutrition, Children's Hospital Colorado, Aurora, Colorado, United States
,
Carleen A. Zebuhr
2   Section of Critical Care, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, United States
› Author Affiliations
Further Information

Publication History

04 December 2014

12 March 2015

Publication Date:
01 September 2015 (online)

Abstract

Achieving optimal nutrition for a child who is receiving acute rehabilitation in the pediatric intensive care unit requires an individualized approach. Nutrition screening and assessment is necessary to identify children at high risk for complications who require targeted interventions. Early enteral nutrition can improve outcomes, and is thus preferred over parenteral nutrition in the absence of gastrointestinal contraindications. Measurement of caloric requirements with indirect calorimetry is essential to accurately prescribe nutrition support, while monitoring body composition can determine efficacy of nutrition therapies employed. The complex care of critically ill children receiving acute rehabilitation is composed of treatments that compete with delivery of prescribed nutrition. Repeated feeding interruptions can lead to nutrition deficits and prolonged recovery. Nutrition bundles that incorporate evidenced-based nutrition algorithms, methods to overcome nutrition barriers, and nutrition monitoring parameters can direct and optimize nutrition care for critically ill children in need of acute rehabilitation.

 
  • References

  • 1 Herridge MS, Cheung AM, Tansey CM , et al; Canadian Critical Care Trials Group. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003; 348 (8) 683-693
  • 2 Turner DA, Cheifetz IM, Rehder KJ , et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med 2011; 39 (12) 2593-2598
  • 3 Pohlman MC, Schweickert WD, Pohlman AS , et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 2010; 38 (11) 2089-2094
  • 4 Morris PE, Goad A, Thompson C , et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36 (8) 2238-2243
  • 5 Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008; 36 (4) 1119-1124
  • 6 Bailey P, Thomsen GE, Spuhler VJ , et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35 (1) 139-145
  • 7 Schweickert WD, Pohlman MC, Pohlman AS , et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678) 1874-1882
  • 8 Hayes Jr D, McConnell PI, Preston TJ, Yates AR, Kirkby S, Galantowicz M. Active rehabilitation with venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation in a pediatric patient. World J Pediatr 2013; 9 (4) 373-374
  • 9 Schmidt F, Sasse M, Boehne M , et al. Concept of “awake venovenous extracorporeal membrane oxygenation” in pediatric patients awaiting lung transplantation. Pediatr Transplant 2013; 17 (3) 224-230
  • 10 Zebuhr C, Sinha A, Skillman H, Buckvold S. Active rehabilitation in a pediatric extracorporeal membrane oxygenation patient. PM R 2014; 6 (5) 456-460
  • 11 de Souza Menezes F, Leite HP, Koch Nogueira PC. Malnutrition as an independent predictor of clinical outcome in critically ill children. Nutrition 2012; 28 (3) 267-270
  • 12 Hulst JM, van Goudoever JB, Zimmermann LJ , et al. The effect of cumulative energy and protein deficiency on anthropometric parameters in a pediatric ICU population. Clin Nutr 2004; 23 (6) 1381-1389
  • 13 Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg 2009; 44 (8) 1601-1605
  • 14 Brown CV, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D. The impact of obesity on severely injured children and adolescents. J Pediatr Surg 2006; 41 (1) 88-91 , discussion 88–91
  • 15 Mehta NM, Compher C ; A.S.P.E.N. Board of Directors. A.S.P.E.N. Clinical Guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr 2009; 33 (3) 260-276
  • 16 Wakeham M, Christensen M, Manzi J , et al. Registered dietitians making a difference: early medical record documentation of estimated energy requirement in critically ill children is associated with higher daily energy intake and with use of the enteral route. J Acad Nutr Diet 2013; 113 (10) 1311-1316
  • 17 Meyer R, Kulinskaya E, Briassoulis G , et al. The challenge of developing a new predictive formula to estimate energy requirements in ventilated critically ill children. Nutr Clin Pract 2012; 27 (5) 669-676
  • 18 Mehta NM, Bechard LJ, Dolan M, Ariagno K, Jiang H, Duggan C. Energy imbalance and the risk of overfeeding in critically ill children. Pediatr Crit Care Med 2011; 12 (4) 398-405
  • 19 Mtaweh H, Smith R, Kochanek PM , et al. Energy expenditure in children after severe traumatic brain injury. Pediatr Crit Care Med 2014; 15 (3) 242-249
  • 20 Dabydeen L, Thomas JE, Aston TJ, Hartley H, Sinha SK, Eyre JA. High-energy and -protein diet increases brain and corticospinal tract growth in term and preterm infants after perinatal brain injury. Pediatrics 2008; 121 (1) 148-156
  • 21 Hart DW, Wolf SE, Herndon DN , et al. Energy expenditure and caloric balance after burn: increased feeding leads to fat rather than lean mass accretion. Ann Surg 2002; 235 (1) 152-161
  • 22 Energy and protein requirements. Report of a joint FAO/WHO/UNU Expert Consultation. World Health Organ Tech Rep Ser 1985; 724: 1-206
  • 23 Schofield WN. Predicting basal metabolic rate, new standards and review of previous work. Hum Nutr Clin Nutr 1985; 39 (Suppl. 01) 5-41
  • 24 Wong JJ, Ong C, Han WM, Lee JH. Protocol-driven enteral nutrition in critically ill children: a systematic review. JPEN J Parenter Enteral Nutr 2014; 38 (1) 29-39
  • 25 Martinez EE, Bechard LJ, Mehta NM. Nutrition algorithms and bedside nutrient delivery practices in pediatric intensive care units: an international multicenter cohort study. Nutr Clin Pract 2014; 29 (3) 360-367
  • 26 Duggan C, Rizzo C, Cooper A , et al. Effectiveness of a clinical practice guideline for parenteral nutrition: a 5-year follow-up study in a pediatric teaching hospital. JPEN J Parenter Enteral Nutr 2002; 26 (6) 377-381
  • 27 Herman R, Btaiche I, Teitelbaum DH. Nutrition support in the pediatric surgical patient. Surg Clin North Am 2011; 91 (3) 511-541
  • 28 Cunningham JJ. Body composition and nutrition support in pediatrics: what to defend and how soon to begin. Nutr Clin Pract 1995; 10 (5) 177-182
  • 29 Doig GS, Simpson F, Sweetman EA , et al; Early PN Investigators of the ANZICS Clinical Trials Group. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309 (20) 2130-2138
  • 30 Casaer MP, Mesotten D, Hermans G , et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365 (6) 506-517
  • 31 Casaer MP, Langouche L, Coudyzer W , et al. Impact of early parenteral nutrition on muscle and adipose tissue compartments during critical illness. Crit Care Med 2013; 41 (10) 2298-2309
  • 32 Mehta NM, Bechard LJ, Cahill N , et al. Nutritional practices and their relationship to clinical outcomes in critically ill children—an international multicenter cohort study. Crit Care Med 2012; 40 (7) 2204-2211
  • 33 Sena MJ, Utter GH, Cuschieri J , et al. Early supplemental parenteral nutrition is associated with increased infectious complications in critically ill trauma patients. J Am Coll Surg 2008; 207 (4) 459-467
  • 34 Botrán M, López-Herce J, Mencía S, Urbano J, Solana MJ, García A. Enteral nutrition in the critically ill child: comparison of standard and protein-enriched diets. J Pediatr 2011; 159 (1) 27-32.e1
  • 35 van Waardenburg DA, de Betue CT, Goudoever JB, Zimmermann LJ, Joosten KF. Critically ill infants benefit from early administration of protein and energy-enriched formula: a randomized controlled trial. Clin Nutr 2009; 28 (3) 249-255
  • 36 McClave SA, Martindale RG, Vanek VW , et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009; 33 (3) 277-316
  • 37 Savage K, Kritas S, Schwarzer A, Davidson G, Omari T. Whey- vs casein-based enteral formula and gastrointestinal function in children with cerebral palsy. JPEN J Parenter Enteral Nutr 2012; 36 (1, Suppl): 118S-123S
  • 38 Meert KL, Daphtary KM, Metheny NA. Gastric vs small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest 2004; 126 (3) 872-878
  • 39 Kamat P, Favaloro-Sabatier J, Rogers K, Stockwell JA. Use of methylene blue spectrophotometry to detect subclinical aspiration in enterally fed intubated pediatric patients. Pediatr Crit Care Med 2008; 9 (3) 299-303
  • 40 Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding on the incidence of pneumonia in critically ill patients: observations from traditional and Bayesian random-effects meta-analysis. Clin Nutr 2013; 32 (1) 8-15
  • 41 Davies AR, Morrison SS, Bailey MJ , et al; ENTERIC Study Investigators; ANZICS Clinical Trials Group. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Crit Care Med 2012; 40 (8) 2342-2348
  • 42 Taha AA, Badr L, Westlake C, Dee V, Mudit M, Tiras KL. Effect of early nutritional support on intensive care unit length of stay and neurological status at discharge in children with severe traumatic brain injury. J Neurosci Nurs 2011; 43 (6) 291-297
  • 43 Mikhailov TA, Kuhn EM, Manzi J , et al. Early enteral nutrition is associated with lower mortality in critically ill children. JPEN J Parenter Enteral Nutr 2014; 38 (4) 459-466
  • 44 Gottschlich MM, Jenkins ME, Mayes T, Khoury J, Kagan RJ, Warden GD. The 2002 Clinical Research Award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after severe burns. J Burn Care Rehabil 2002; 23 (6) 401-415
  • 45 Venter M, Rode H, Sive A, Visser M. Enteral resuscitation and early enteral feeding in children with major burns—effect on McFarlane response to stress. Burns 2007; 33 (4) 464-471
  • 46 Khorasani EN, Mansouri F. Effect of early enteral nutrition on morbidity and mortality in children with burns. Burns 2010; 36 (7) 1067-1071
  • 47 Horn D, Chaboyer W. Gastric feeding in critically ill children: a randomized controlled trial. Am J Crit Care 2003; 12 (5) 461-468
  • 48 Tume L, Carter B, Latten L. A UK and Irish survey of enteral nutrition practices in paediatric intensive care units. Br J Nutr 2013; 109 (7) 1304-1322
  • 49 Keehn A, O'Brien C, Mazurak V , et al. Epidemiology of interruptions to nutrition support in critically ill children in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2015; 39 (2) 211-217
  • 50 Mehta NM, McAleer D, Hamilton S , et al. Challenges to optimal enteral nutrition in a multidisciplinary pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2010; 34 (1) 38-45
  • 51 King W, Petrillo T, Pettignano R. Enteral nutrition and cardiovascular medications in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2004; 28 (5) 334-338
  • 52 Mancl EE, Muzevich KM. Tolerability and safety of enteral nutrition in critically ill patients receiving intravenous vasopressor therapy. JPEN J Parenter Enteral Nutr 2013; 37 (5) 641-651
  • 53 Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 2010; 19 (3) 261-268
  • 54 Gay PC. Complications of noninvasive ventilation in acute care. Respir Care 2009; 54 (2) 246-257 , discussion 257–258
  • 55 Lyons KA, Brilli RJ, Wieman RA, Jacobs BR. Continuation of transpyloric feeding during weaning of mechanical ventilation and tracheal extubation in children: a randomized controlled trial. JPEN J Parenter Enteral Nutr 2002; 26 (3) 209-213
  • 56 Pousman RM, Pepper C, Pandharipande P , et al. Feasibility of implementing a reduced fasting protocol for critically ill trauma patients undergoing operative and nonoperative procedures. JPEN J Parenter Enteral Nutr 2009; 33 (2) 176-180
  • 57 Heyland DK, Dhaliwal R, Lemieux M, Wang M, Day AG. Implementing the PEP uP protocol in critical care units in Canada: results of a multicenter, quality improvement study. JPEN J Parenter Enteral Nutr 2015; 39 (6) 698-706
  • 58 Lichtenberg K, Guay-Berry P, Pipitone A, Bondy A, Rotello L. Compensatory increased enteral feeding goal rates: a way to achieve optimal nutrition. Nutr Clin Pract 2010; 25 (6) 653-657
  • 59 McClave SA, Lukan JK, Stefater JA , et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005; 33 (2) 324-330
  • 60 Poulard F, Dimet J, Martin-Lefevre L , et al. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr 2010; 34 (2) 125-130
  • 61 Reignier J, Mercier E, Le Gouge A , et al; Clinical Research in Intensive Care and Sepsis (CRICS) Group. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 2013; 309 (3) 249-256
  • 62 Weckwerth JA. Monitoring enteral nutrition support tolerance in infants and children. Nutr Clin Pract 2004; 19 (5) 496-503
  • 63 Hempel S, Newberry SJ, Maher AR , et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA 2012; 307 (18) 1959-1969
  • 64 Simakachorn N, Bibiloni R, Yimyaem P , et al. Tolerance, safety, and effect on the faecal microbiota of an enteral formula supplemented with pre- and probiotics in critically ill children. J Pediatr Gastroenterol Nutr 2011; 53 (2) 174-181
  • 65 Kumar S, Bansal A, Chakrabarti A, Singhi S. Evaluation of efficacy of probiotics in prevention of candida colonization in a PICU-a randomized controlled trial. Crit Care Med 2013; 41 (2) 565-572
  • 66 Cvijanovich NZ, King JC, Flori HR, Gildengorin G, Wong HR. Zinc homeostasis in pediatric critical illness. Pediatr Crit Care Med 2009; 10 (1) 29-34
  • 67 Madden K, Feldman HA, Smith EM , et al. Vitamin D deficiency in critically ill children. Pediatrics 2012; 130 (3) 421-428
  • 68 McNally JD, Menon K, Chakraborty P , et al; Canadian Critical Care Trials Group. The association of vitamin D status with pediatric critical illness. Pediatrics 2012; 130 (3) 429-436
  • 69 Lima LF, Leite HP, Taddei JA. Low blood thiamine concentrations in children upon admission to the intensive care unit: risk factors and prognostic significance. Am J Clin Nutr 2011; 93 (1) 57-61
  • 70 Barbosa E, Faintuch J, Machado Moreira EA , et al. Supplementation of vitamin E, vitamin C, and zinc attenuates oxidative stress in burned children: a randomized, double-blind, placebo-controlled pilot study. J Burn Care Res 2009; 30 (5) 859-866
  • 71 Carcillo JA, Dean JM, Holubkov R , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN). The randomized comparative pediatric critical illness stress-induced immune suppression (CRISIS) prevention trial. Pediatr Crit Care Med 2012; 13 (2) 165-173
  • 72 Mehta NM, Corkins MR, Lyman B , et al; American Society for Parenteral and Enteral Nutrition Board of Directors. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013; 37 (4) 460-481
  • 73 Leite HP, de Lima LF, de Oliveira Iglesias SB, Pacheco JC, de Carvalho WB. Malnutrition may worsen the prognosis of critically ill children with hyperglycemia and hypoglycemia. JPEN J Parenter Enteral Nutr 2013; 37 (3) 335-341
  • 74 Byrnes MC, Stangenes J. Refeeding in the ICU: an adult and pediatric problem. Curr Opin Clin Nutr Metab Care 2011; 14 (2) 186-192
  • 75 Skipper A. Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases. Nutr Clin Pract 2012; 27 (1) 34-40
  • 76 Fuentebella J, Kerner JA. Refeeding syndrome. Pediatr Clin North Am 2009; 56 (5) 1201-1210
  • 77 Dunn RL, Stettler N, Mascarenhas MR. Refeeding syndrome in hospitalized pediatric patients. Nutr Clin Pract 2003; 18 (4) 327-332
  • 78 de Onis M, Lobstein T. Defining obesity risk status in the general childhood population: which cut-offs should we use?. Int J Pediatr Obes 2010; 5 (6) 458-460
  • 79 Bailey KA. Special considerations in the critically ill morbidly obese child. Crit Care Clin 2010; 26 (4) 699-702
  • 80 Jesuit C, Dillon C, Compher C, Lenders CM ; American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition support of hospitalized pediatric patients with obesity. JPEN J Parenter Enteral Nutr 2010; 34 (1) 13-20
  • 81 Lazzer S, Agosti F, De Col A, Sartorio A. Development and cross-validation of prediction equations for estimating resting energy expenditure in severely obese Caucasian children and adolescents. Br J Nutr 2006; 96 (5) 973-979
  • 82 McDuffie JR, Adler-Wailes DC, Elberg J , et al. Prediction equations for resting energy expenditure in overweight and normal-weight black and white children. Am J Clin Nutr 2004; 80 (2) 365-373
  • 83 Molnár D, Jeges S, Erhardt E, Schutz Y. Measured and predicted resting metabolic rate in obese and nonobese adolescents. J Pediatr 1995; 127 (4) 571-577
  • 84 Maffeis C, Schutz Y, Micciolo R, Zoccante L, Pinelli L. Resting metabolic rate in six- to ten-year-old obese and nonobese children. J Pediatr 1993; 122 (4) 556-562
  • 85 Phillips S, Edlbeck A, Kirby M, Goday P. Ideal body weight in children. Nutr Clin Pract 2007; 22 (2) 240-245
  • 86 Rodriguez NA, Jeschke MG, Williams FN, Kamolz LP, Herndon DN. Nutrition in burns: Galveston contributions. JPEN J Parenter Enteral Nutr 2011; 35 (6) 704-714
  • 87 Przkora R, Herndon DN, Sherrard DJ, Chinkes DL, Klein GL. Pamidronate preserves bone mass for at least 2 years following acute administration for pediatric burn injury. Bone 2007; 41 (2) 297-302
  • 88 Rowan CJ, Gillanders LK, Paice RL, Judson JA. Is early enteral feeding safe in patients who have suffered spinal cord injury?. Injury 2004; 35 (3) 238-242
  • 89 Jia X, Kowalski RG, Sciubba DM, Geocadin RG. Critical care of traumatic spinal cord injury. J Intensive Care Med 2013; 28 (1) 12-23
  • 90 Wong S, Derry F, Jamous A, Hirani SP, Grimble G, Forbes A. The prevalence of malnutrition in spinal cord injuries patients: a UK multicentre study. Br J Nutr 2012; 108 (5) 918-923
  • 91 Carlson SJ. Current nutrition management of infants with chronic lung disease. Nutr Clin Pract 2004; 19 (6) 581-586
  • 92 Poruk KE, Davis RH, Smart AL , et al. Observational study of caloric and nutrient intake, bone density, and body composition in infants and children with spinal muscular atrophy type I. Neuromuscul Disord 2012; 22 (11) 966-973
  • 93 Hogan SE. Body composition and resting energy expenditure of individuals with Duchenne and Becker muscular dystrophy. Can J Diet Pract Res 2008; 69 (4) 208-212
  • 94 Badireddi S, Bercher AJ, Holder JB, Mireles-Cabodevila E. Vitamin D deficiency in patients with neuromuscular diseases with chronic respiratory failure. JPEN J Parenter Enteral Nutr 2014; 38 (5) 602-607
  • 95 Azevedo ZM, Moore DC, de Matos FA , et al. Bioelectrical impedance parameters in critically ill children: importance of reactance and resistance. Clin Nutr 2013; 32 (5) 824-829
  • 96 Silva C, Amaral TF, Silva D, Oliveira BM, Guerra A. Handgrip strength and nutrition status in hospitalized pediatric patients. Nutr Clin Pract 2014; 29 (3) 380-385
  • 97 Boehm KA, Helms RA, Storm MC. Assessing the validity of adjusted urinary urea nitrogen as an estimate of total urinary nitrogen in three pediatric populations. JPEN J Parenter Enteral Nutr 1994; 18 (2) 172-176
  • 98 Letton RW, Chwals WJ, Jamie A, Charles B. Early postoperative alterations in infant energy use increase the risk of overfeeding. J Pediatr Surg 1995; 30 (7) 988-992 , discussion 992–993
  • 99 Moghazy AM, Adly OA, Abbas AH, Moati TA, Ali OS, Mohamed BA. Assessment of the relation between prealbumin serum level and healing of skin-grafted burn wounds. Burns 2010; 36 (4) 495-500
  • 100 Davis CJ, Sowa D, Keim KS, Kinnare K, Peterson S. The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center. JPEN J Parenter Enteral Nutr 2012; 36 (2) 197-204
  • 101 Ong C, Han WM, Wong JJ, Lee JH. Nutrition biomarkers and clinical outcomes in critically ill children: a critical appraisal of the literature. Clin Nutr 2014; 33 (2) 191-197
  • 102 Ferrie S, Allman-Farinelli M. Commonly used “nutrition” indicators do not predict outcome in the critically ill: a systematic review. Nutr Clin Pract 2013; 28 (4) 463-484
  • 103 Santana e Meneses JF, Leite HP, de Carvalho WB, Lopes Jr E. Hypophosphatemia in critically ill children: prevalence and associated risk factors. Pediatr Crit Care Med 2009; 10 (2) 234-238
  • 104 Kilic O, Demirkol D, Ucsel R, Citak A, Karabocuoglu M. Hypophosphatemia and its clinical implications in critically ill children: a retrospective study. J Crit Care 2012; 27 (5) 474-479