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Bear DE, Griffith D, Puthucheary ZA. Emerging outcome measures for nutrition trials in the critically ill. Curr Opin Clin Nutr Metab Care 2018; 21:417-422. [PMID: 30148741 DOI: 10.1097/mco.0000000000000507] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mortality has long been the gold-standard outcome measure for intensive care clinical trials. However, as the critical care community begins to understand and accept that survivorship is associated with functional disability and a health and socioeconomic burden, the clinical and research focus has begun to shift towards long-term physical function RECENT FINDINGS: To use mortality as a primary outcome measure, one would either have to choose an improbable effect (e.g. a difference of 5-10% in mortality as a result of a single intervention) or recruit a larger number of patients, the latter being unfeasible for most critical care trials.Outcome measures will need to match interventions. As an example, amino acids, or intermittent feeding, can stimulate muscle protein synthesis, and so prevention of muscle wasting may seem an appropriate outcome measure when assessing the effectiveness of these interventions. Testing the effectiveness of these interventions requires the development of novel outcome measures that are targeted and acceptable to patients. We describe advancements in dual-energy X-ray absorptiometry scanning, bio-impedence analysis, MRI and muscle ultrasound in this patient group that are beginning to address this development need. SUMMARY New approaches to outcome assessment are beginning to appear in post-ICU research, which promise to improve our understanding of nutrition and exercise interventions on skeletal muscle structure, composition and function, without causing undue suffering to the patient.
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Affiliation(s)
- Danielle E Bear
- Department of Nutrition and Dietetics
- Department of Critical Care
- Lane Fox Clinical Respiratory Research Unit, Guy's and St Thomas' NHS Foundation Trust
- Centre for Human and Applied Physiological Sciences, King's College London
| | - David Griffith
- Anaesthesia, Critical Care and Pain Medicine, The University of Edinburgh, Edinburgh
| | - Zudin A Puthucheary
- Centre for Human and Applied Physiological Sciences, King's College London
- Centre for Human Health and Performance, Department of Medicine, University College London
- Adult Intensive Care Unit, Royal Free Hospital NHS Foundation Trust London, London, UK
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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Bear DE, Smith E, Barrett NA. Nutrition Support in Adult Patients Receiving Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2018; 33:738-746. [DOI: 10.1002/ncp.10211] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Danielle E. Bear
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
| | - Elizabeth Smith
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
| | - Nicholas A. Barrett
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
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Puthucheary ZA, Astin R, Mcphail MJW, Saeed S, Pasha Y, Bear DE, Constantin D, Velloso C, Manning S, Calvert L, Singer M, Batterham RL, Gomez-Romero M, Holmes E, Steiner MC, Atherton PJ, Greenhaff P, Edwards LM, Smith K, Harridge SD, Hart N, Montgomery HE. Metabolic phenotype of skeletal muscle in early critical illness. Thorax 2018; 73:926-935. [PMID: 29980655 DOI: 10.1136/thoraxjnl-2017-211073] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 05/17/2018] [Accepted: 05/28/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To characterise the sketetal muscle metabolic phenotype during early critical illness. METHODS Vastus lateralis muscle biopsies and serum samples (days 1 and 7) were obtained from 63 intensive care patients (59% male, 54.7±18.0 years, Acute Physiology and Chronic Health Evaluation II score 23.5±6.5). MEASUREMENTS AND MAIN RESULTS From day 1 to 7, there was a reduction in mitochondrial beta-oxidation enzyme concentrations, mitochondrial biogenesis markers (PGC1α messenger mRNA expression (-27.4CN (95% CI -123.9 to 14.3); n=23; p=0.025) and mitochondrial DNA copy number (-1859CN (IQR -5557-1325); n=35; p=0.032). Intramuscular ATP content was reduced compared tocompared with controls on day 1 (17.7mmol/kg /dry weight (dw) (95% CI 15.3 to 20.0) vs. 21.7 mmol/kg /dw (95% CI 20.4 to 22.9); p<0.001) and decreased over 7 days (-4.8 mmol/kg dw (IQR -8.0-1.2); n=33; p=0.001). In addition, the ratio of phosphorylated:total AMP-K (the bioenergetic sensor) increased (0.52 (IQR -0.09-2.6); n=31; p<0.001). There was an increase in intramuscular phosphocholine (847.2AU (IQR 232.5-1672); n=15; p=0.022), intramuscular tumour necrosis factor receptor 1 (0.66 µg (IQR -0.44-3.33); n=29; p=0.041) and IL-10 (13.6 ng (IQR 3.4-39.0); n=29; p=0.004). Serum adiponectin (10.3 µg (95% CI 6.8 to 13.7); p<0.001) and ghrelin (16.0 ng/mL (IQR -7-100); p=0.028) increased. Network analysis revealed a close and direct relationship between bioenergetic impairment and reduction in muscle mass and between intramuscular inflammation and impaired anabolic signaling. ATP content and muscle mass were unrelated to lipids delivered. CONCLUSIONS Decreased mitochondrial biogenesis and dysregulated lipid oxidation contribute to compromised skeletal muscle bioenergetic status. In addition, intramuscular inflammation was associated with impaired anabolic recovery with lipid delivery observed as bioenergetically inert. Future clinical work will focus on these key areas to ameliorate acute skeletal muscle wasting. TRIAL REGISTRATION NUMBER NCT01106300.
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Affiliation(s)
- Zudin A Puthucheary
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Ronan Astin
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
| | - Mark J W Mcphail
- Hepatology and Gastroenterology, St Mary's Hospital, Imperial College London, London, UK
- Institute of Liver Studies, Kings College Hospital NHS Foundation Trust, London, UK
| | - Saima Saeed
- Wolfson Institute Centre for Intensive Care Medicine, University College London, London, UK
| | - Yasmin Pasha
- Hepatology and Gastroenterology, St Mary's Hospital, Imperial College London, London, UK
| | - Danielle E Bear
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, London, UK
| | - Despina Constantin
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Cristiana Velloso
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Sean Manning
- Centre for Obesity Research, University College London, London, UK
- National Institute of Health Research, UCLH Biomedical Research Centre, University College London Hospitals, London
- School of Medicine, University College Cork, Cork, Ireland
| | - Lori Calvert
- Northwest Anglia foundation Trust, Peterborough City Hospital NHS Trust, Peterborough, UK
| | - Mervyn Singer
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Wolfson Institute Centre for Intensive Care Medicine, University College London, London, UK
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK
- National Institute of Health Research, UCLH Biomedical Research Centre, University College London Hospitals, London
| | - Maria Gomez-Romero
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, London, UK
| | - Elaine Holmes
- Biomolecular Medicine, Division of Computational and Systems Medicine, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, London, UK
| | - Michael C Steiner
- Institute for Lung Health, Leicester NIHR Biomedical Research Centre-Respiratory, University of Leicester, Leicester, UK
| | - Philip J Atherton
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Paul Greenhaff
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Lindsay M Edwards
- Digital, Data & Analytics Unit, Respiratory Therapy Area, GlaxoSmithKline Medicines Research Centre, Stevenage, UK
| | - Kenneth Smith
- Medical Research Council/Arthritis Research UK Centre for Musculoskeletal Aging Research, National Institute for Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Stephen D Harridge
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, London, UK
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' Foundation Trust, London, UK
| | - Hugh E Montgomery
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
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Berney SC, Rose JW, Denehy L, Granger CL, Ntoumenopoulos G, Crothers E, Steel B, Clarke S, Skinner EH. Commencing Out-of-Bed Rehabilitation in Critical Care-What Influences Clinical Decision-Making? Arch Phys Med Rehabil 2018; 100:261-269.e2. [PMID: 30172644 DOI: 10.1016/j.apmr.2018.07.438] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. DESIGN A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. SETTING Four tertiary metropolitan ICUs. PARTICIPANTS Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. RESULTS There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. CONCLUSION These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.
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Affiliation(s)
- Sue C Berney
- Physiotherapy Department, Austin Health, Melbourne, Australia; Physiotherapy Department, The University of Melbourne, Melbourne, Australia; Institute for Breathing and Sleep, Melbourne, Australia.
| | - Joleen W Rose
- Physiotherapy Department, Austin Health, Melbourne, Australia
| | - Linda Denehy
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia
| | - Catherine L Granger
- Physiotherapy Department, The University of Melbourne, Melbourne, Australia; Allied Health Department, Melbourne Health, Melbourne, Australia
| | | | - Elise Crothers
- Physiotherapy Department, St Vincent's Hospital, Darlinghurst, Australia
| | | | - Sandy Clarke
- Statistical Consulting Centre, School of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia
| | - Elizabeth H Skinner
- Institute for Breathing and Sleep, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University, Melbourne, Australia
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Morimoto Y, Sekino M, Eishi K, Kozu R. Recovery of muscle weakness and physical function in a patient with severe ICU-acquired weakness following pulmonary embolism: A case report. Clin Case Rep 2018; 6:1214-1218. [PMID: 29988636 PMCID: PMC6028372 DOI: 10.1002/ccr3.1576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 11/08/2022] Open
Abstract
Although ICU-AW is a common condition in critically ill, it is unclear which intervention is best to treat. We applied combined exercise training and nutritional supplementation, and these were effective to recover the skeletal muscle function and exercise capacity. We should recognize necessity of nutritional support in ICU-AW patients.
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Affiliation(s)
- Yosuke Morimoto
- Department of Rehabilitation MedicineNagasaki University HospitalNagasakiJapan
| | - Motohiro Sekino
- Department of Intensive Care UnitNagasaki University HospitalNagasakiJapan
| | - Kiyoyuki Eishi
- Department of Cardiovascular SurgeryNagasaki University HospitalNagasakiJapan
| | - Ryo Kozu
- Department of Rehabilitation MedicineNagasaki University HospitalNagasakiJapan
- Department of Cardiopulmonary Rehabilitation ScienceNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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Badjatia N, Cremers S, Claassen J, Connolly ES, Mayer SA, Karmally W, Seres D. Serum glutamine and hospital-acquired infections after aneurysmal subarachnoid hemorrhage. Neurology 2018; 91:e421-e426. [PMID: 29959259 DOI: 10.1212/wnl.0000000000005902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/27/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To understand nutritional and inflammatory factors contributing to serum glutamine levels and their relationship to hospital-acquired infections (HAIs) after aneurysmal subarachnoid hemorrhage (SAH). METHODS A prospective observational study of patients with SAH who had measurements of daily caloric intake and C-reactive protein, transthyretin, tumor necrosis factor α receptor 1a (TNFαR1a), glutamine, and nitrogen balance performed within 4 preset time periods during the 14 days after SAH. Factors associated with glutamine levels and HAIs were analyzed with multivariable regression. HAIs were tracked daily for time-to-event analyses. Outcome 3 months after SAH was assessed by the Telephone Interview for Cognitive Status and modified Rankin Scale. RESULTS There were 77 patients with an average age of 55 ± 15 years. HAIs developed in 18 (23%) on mean SAH day 8 ± 3. In a multivariable linear regression model, negative nitrogen balance (p = 0.02) and elevated TNFαR1a (p = 0.04) were independently associated with higher glutamine levels during the study period. The 14-day mean glutamine levels were lower in patients who developed HAI (166 ± 110 vs 236 ± 81 μg/mL, p = 0.004). Poor admission Hunt and Hess grade (p = 0.04) and lower glutamine levels (p = 0.02) predicted time to first HAI. Low 14-day mean levels of glutamine were associated with a poor recovery on the Telephone Interview for Cognitive Status score (p = 0.03) and modified Rankin Scale score (p = 0.04) at 3 months after injury. CONCLUSIONS Declining glutamine levels in the first 14 days after SAH are influenced by inflammation and associated with an increased risk of HAI.
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Affiliation(s)
- Neeraj Badjatia
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY.
| | - Serge Cremers
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Jan Claassen
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - E Sander Connolly
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephan A Mayer
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Wahida Karmally
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
| | - David Seres
- From the Section of Neurocritical Care (N.B.), Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore; Neurological Institute of New York (J.C., E.S.C.), NY; Department of Neurology (S.A.M., W.K.), Henry Ford Hospital, Detroit, MI; and Institute of Human Nutrition and Division of Preventive Medicine and Nutrition (S.C., W.K.), Department of Internal Medicine (D.S.), Columbia University College of Physicians and Surgeons, New York, NY
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Abstract
PURPOSE OF REVIEW Protein delivery as well as exercise of critically ill in clinical practice is still a highly debated issue. Here we discuss only the most recent updates in the literature concerning protein nutrition and exercise of the critically ill. RECENT FINDINGS By lack of randomized controlled trial (RCTs) in protein nutrition we discuss four post-hoc analyses of nutrition studies and one experimental study in mice. Studies mainly confirm some insights that protein and energy effects are separate and that the trajectory of the patient in the ICU might change these effects. Exercise has been studied much more extensively with RCTs in the last year, although also here the differences between patient groups and timing of intervention might play their roles. Overall the effects of protein nutrition and exercise appear to be beneficial. However, studies into the differential effects of protein nutrition and/or exercise, and optimization of their combined use, have not been performed yet and are on the research agenda. SUMMARY Optimal protein nutrition, optimal exercise intervention as well as the optimal combination of nutrition, and exercise may help to improve long-term physical performance outcome in the critically ill patients.
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Heyland DK, Stapleton R, Compher C. Should We Prescribe More Protein to Critically Ill Patients? Nutrients 2018; 10:E462. [PMID: 29642451 PMCID: PMC5946247 DOI: 10.3390/nu10040462] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/30/2022] Open
Abstract
In the context of critical illness, evidence suggests that exogenous protein/amino acid supplementation has the potential to favorably impact whole-body protein balance. Whether this translates into retention of muscle, greater muscle strength, and improved survival and physical recovery of critically ill patients remains uncertain. The purpose of this brief commentary is to provide an overview of the clinical evidence for and against increasing protein doses and to introduce two new trials that will add considerably to our evolving understanding of protein requirements in the critically ill adult patient.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
- Department of Public Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada.
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
| | - Renee Stapleton
- Pulmonary and Critical Care Division, University of Vermont College of Medicine, Burlington, VT 05405, USA.
| | - Charlene Compher
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Bear DE, Parry SM, Puthucheary ZA. Can the critically ill patient generate sufficient energy to facilitate exercise in the ICU? Curr Opin Clin Nutr Metab Care 2018; 21:110-115. [PMID: 29232263 DOI: 10.1097/mco.0000000000000446] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Trials of physical rehabilitation post critical illness have yet to deliver improved health-related quality of life in critical illness survivors. Muscle mass and strength are lost rapidly in critical illness and a proportion of patients continue to do so resulting in increased mortality and functional disability. Addressing this issue is therefore fundamental for recovery from critical illness. RECENT FINDINGS Altered mitochondrial function occurs in the critically ill and is likely to result in decreased adenosine tri-phosphate (ATP) production. Muscle contraction is a process that requires ATP. The metabolic demands of exercise are poorly understood in the ICU setting. Recent research has highlighted that there is significant heterogeneity in energy requirements between critically ill individuals undertaking the same functional activities, such as sit-to-stand. Nutrition in the critically ill is currently thought of in terms of carbohydrates, fat and protein. It may be that we need to consider nutrition in a more contextual manner such as energy generation or management of protein homeostasis. SUMMARY Current nutritional support practices in critically ill patients do not lead to improvements in physical and functional outcomes, and it may be that alternative methods of delivery or substrates are needed.
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Affiliation(s)
- Danielle E Bear
- Department of Nutrition and Dietetics
- Department of Critical Care
- Lane Fox Research Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Zudin A Puthucheary
- Centre for Human Health and Performance, Department of Medicine, University College London
- Department of Anaesthesia and Intensive Care, Royal Free Hospital
- Centre of Human and Aerospace Physiological Sciences, King's College London, London, UK
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Patel JJ, Rosenthal MD, Heyland DK. Intermittent versus continuous feeding in critically ill adults. Curr Opin Clin Nutr Metab Care 2018; 21:116-120. [PMID: 29232262 DOI: 10.1097/mco.0000000000000447] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Early enteral nutrition is recommended in critically ill adult patients. The optimal method of administering enteral nutrition remains unknown. Continuous enteral nutrition administration in critically ill patients remains the most common practice worldwide; however, its practice has recently been called into question in favor of intermittent enteral nutrition administration, where volume is infused multiple times per day. This review will outline the key differences between continuous and intermittent enteral nutrition, describe the metabolic responses to continuous and intermittent enteral nutrition administration and outline recent studies comparing continuous with intermittent enteral nutrition administration on outcomes in critically ill adults. RECENT FINDINGS In separate studies, healthy humans and critically ill patients receiving intermittent nutrition (infused over 3 h) had improved whole body protein balance from negative to positive. These studies did not have an isonitrogenous control group. A randomized controlled trial of intermittent bolus versus continuous enteral nutrition in healthy humans found that intermittent bolus feeding increased mesenteric arterial blood flow, increased insulin and peptide YY and reduced blood glucose concentration. A randomized controlled trial comparing intermittent bolus to continuous enteral nutrition in critically ill patients did not demonstrate clinically relevant differences in glycemic variability, insulin use or tube feeding volume or caloric intake between the two groups. SUMMARY Studies in healthy humans suggest that intermittent nutrient administration, as opposed to continuous, improves whole body protein synthesis. Unfortunately, similarly designed studies are lacking for critically ill patients. Future studies evaluating the impact of intermittent versus continuous nutrition administration on critical care outcomes should take into account factors such as protein quantity, protein quality and delivery route (enteral and/or parenteral). Until further studies are conducted in critically ill patients, a recommendation for or against intermittent nutrition delivery cannot be made.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Martin D Rosenthal
- Division of Acute Care Surgery, University of Florida, Gainesville, Florida, USA
| | - Daren K Heyland
- Division of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Fetterplace K, Deane AM, Tierney A, Beach L, Knight LD, Rechnitzer T, Forsyth A, Mourtzakis M, Presneill J, MacIsaac C. Targeted full energy and protein delivery in critically ill patients: a study protocol for a pilot randomised control trial (FEED Trial). Pilot Feasibility Stud 2018; 4:52. [PMID: 29484196 PMCID: PMC5819238 DOI: 10.1186/s40814-018-0249-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 02/02/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes. METHODS This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes. DISCUSSION This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.
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Affiliation(s)
- Kate Fetterplace
- Department of Clinical Nutrition, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Adam M. Deane
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Audrey Tierney
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
| | - Lisa Beach
- Department of Physiotherapy, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Laura D. Knight
- Department of Physiotherapy, Allied Health, Royal Melbourne Hospital, Melbourne, Australia
| | - Thomas Rechnitzer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Adrienne Forsyth
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Australia
| | - Marina Mourtzakis
- Department of Kinesiology, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Canada
| | - Jeffrey Presneill
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Christopher MacIsaac
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Australia
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Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert Rev Respir Med 2018; 12:203-215. [PMID: 29376440 DOI: 10.1080/17476348.2018.1433034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.
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Affiliation(s)
- Linda Denehy
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Doa El-Ansary
- b Department of Cardiothoracic Surgery , Royal Melbourne Hospital, Royal Parade , Parkville , Australia
| | - Selina M Parry
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
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Heyland DK, Davidson J, Skrobik Y, des Ordons AR, Van Scoy LJ, Day AG, Vandall-Walker V, Marshall AP. Improving partnerships with family members of ICU patients: study protocol for a randomized controlled trial. Trials 2018; 19:3. [PMID: 29301555 PMCID: PMC5753514 DOI: 10.1186/s13063-017-2379-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 11/24/2017] [Indexed: 11/24/2022] Open
Abstract
Background Over the last decade, health care delivery has shifted to partnering with patients and their families to improve health and quality of care, and to lower costs. Partnering with family members (FMs) of critically ill patients who lack capacity is particularly important for improving experiences and outcomes for both patients and FMs. How best to apply such partnering strategies, however, is yet unknown. The IMPACT trial will evaluate two interventions that enable partnerships with families of critically ill patients, each in a distinct content area, but similar in that they empower and support FMs. Methods This multi-center, open-label, randomized, phase II clinical trial aims to randomize 150 older, long-stay ICU patients and their families into one of three groups (50 in each group): (1) The OPTimal nutrition by Informing and Capacitating FMs of best practices (OPTICs) group, a multi-faceted intervention to engage and empower FMs to advocate for, and audit, best nutritional practices for their critically ill FMs, (2) A web-based decision-support intervention called the ICU Workbook (The Canadian Researchers at the End of Life Network (CARENET) ICU Workbook; https://www.myicuguide.ca/. Accessed 3 Feb 2017.) to support families in shared decision-making process regarding goals of medical treatments, and (3) Usual care. The main outcomes for this trial include nutritional adequacy in hospital and hand-grip strength prior to hospital discharge; satisfaction with decision-making; decision conflict; and degree of shared decision-making. Discussion With the goal of improving the functional recovery of nutritionally high-risk older patients and the quality of care at the end of life for these patients and their FMs in the ICU, we have proposed two novel family capacitation strategies. We hope that the nutrition and decision-support interventions implemented and evaluated in our study will contribute to the evidentiary basis for best family partnered care pathways focused on optimizing the quality of ICU care for patients with life-threatening illness and their families. Trial registration Clinical trials.gov, ID: NCT02920086. Registered on 30 September 2016. Protocol version dated 11 October 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2379-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada. .,Kingston General Hospital, Angada 4, Kingston, ON, K7L 2 V7, Canada.
| | - Judy Davidson
- EBP/Research Nurse Liaison, University of California, San Diego Health, San Diego, CA, USA
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine and Division of Palliative Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren J Van Scoy
- Department of Medicine and Humanities, Division of Pulmonary, Allergy and Critical Care, Pennsylvania State University, Hershey, PA, USA
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Virginia Vandall-Walker
- Faculty of Health Disciplines, Athabasca University, Athabasca, AB, Canada.,Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Andrea P Marshall
- Menzies Health Institute Queensland, Griffith University and Gold Coast Health, Southport, QLD, Australia
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Needham DM, Sepulveda KA, Dinglas VD, Chessare CM, Friedman LA, Bingham CO, Turnbull AE. Core Outcome Measures for Clinical Research in Acute Respiratory Failure Survivors. An International Modified Delphi Consensus Study. Am J Respir Crit Care Med 2017; 196:1122-1130. [PMID: 28537429 DOI: 10.1164/rccm.201702-0372oc] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Research evaluating acute respiratory failure (ARF) survivors' outcomes after hospital discharge has substantial heterogeneity in terms of the measurement instruments used, creating barriers to synthesizing study data. OBJECTIVES To identify a minimum set of core outcome measures that are essential to include in all clinical research studies evaluating ARF survivors after discharge. METHODS We conducted a three-round modified Delphi consensus process with 77 participants (47% female, 55% outside the United States), including clinical researchers from more than 16 countries across six continents, patients/caregivers, clinicians, and research funders. Participants reviewed standardized information on measure instruments for seven consensus-derived outcomes plus one recommended outcome. MEASUREMENTS AND MAIN RESULTS Response rates were 91 to 97% across the three rounds. Among 75 measurement instruments evaluated, the following met a priori consensus criteria: EQ-5D and 36-item Short Form Health Survey version 2 (optional) for the "satisfaction with life and personal enjoyment" and "pain" outcomes, and both the Hospital Anxiety and Depression Scale and the Impact of Events Scale-Revised for the "mental health" outcome. No measures reached consensus for the following outcomes: cognition, muscle and/or nerve function, physical function, and pulmonary function. All measures considered for pulmonary function met consensus criteria for exclusion. The following measures did not reach the threshold for consensus but achieved the highest scores for their respective outcomes: the Montreal Cognitive Assessment (cognition), manual muscle testing and handgrip dynamometry (muscle and/or nerve function), and 6-minute-walk test (physical function). CONCLUSIONS This Core Outcome Measurement Set is recommended for use in all clinical research evaluating ARF survivors after hospital discharge. In the future, researchers should evaluate measures for outcomes not reaching consensus.
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Affiliation(s)
- Dale M Needham
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine.,3 Department of Physical Medicine and Rehabilitation, School of Medicine
| | - Kristin A Sepulveda
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine
| | - Victor D Dinglas
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine
| | - Caroline M Chessare
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine
| | - Lisa Aronson Friedman
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine
| | - Clifton O Bingham
- 4 Division of Rheumatology, School of Medicine.,5 Division of Allergy and Clinical Immunology, School of Medicine, and
| | - Alison E Turnbull
- 1 Outcomes After Critical Illness and Surgery Group.,2 Division of Pulmonary and Critical Care Medicine, School of Medicine.,6 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Bear DE, Wandrag L, Merriweather JL, Connolly B, Hart N, Grocott MPW. The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review. Crit Care 2017; 21:226. [PMID: 28841893 PMCID: PMC6389279 DOI: 10.1186/s13054-017-1810-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.
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Affiliation(s)
- Danielle E. Bear
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Liesl Wandrag
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith L. Merriweather
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bronwen Connolly
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Aerospace Physiological Sciences, King’s College London, London, UK
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC Australia
| | - Nicholas Hart
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - on behalf of the Enhanced Recovery After Critical Illness Programme Group (ERACIP) investigators
- Department of Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Asthma, Allergy, and Lung Biology, King’s College London, London, UK
- National Institute for Health Research (NIHR), Guy’s and St Thomas’ NHS Foundation Biomedical Research Centre, London, UK
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Human and Aerospace Physiological Sciences, King’s College London, London, UK
- Department of Physiotherapy, The University of Melbourne, Melbourne, VIC Australia
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
- Respiratory and Critical Care Research Theme, Southampton NIHR Biomedical Research Centre, Southampton, UK
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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The intensive care medicine research agenda in nutrition and metabolism. Intensive Care Med 2017; 43:1239-1256. [PMID: 28374096 PMCID: PMC5569654 DOI: 10.1007/s00134-017-4711-6] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/02/2017] [Indexed: 01/04/2023]
Abstract
Purpose The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years. Methods Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0–4). Potential studies were ranked on the basis of average score. Results Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies. Conclusions Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4711-6) contains supplementary material, which is available to authorized users.
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Alugubelli NR, Al-Ani A, Needham DM, Parker AM. Understanding early goal-directed mobilization in the surgical intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:176. [PMID: 28480212 DOI: 10.21037/atm.2017.03.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Navya Reddy Alugubelli
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Awsse Al-Ani
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ann M Parker
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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70
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Schädler D, Kaiser L, Malchow B, Becher T, Elke G, Frerichs I, Küchler T, Weiler N. [Health-related quality of life after mechanical ventilation in the intensive care unit]. Anaesthesist 2017; 66:240-248. [PMID: 28175941 DOI: 10.1007/s00101-017-0276-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 01/10/2017] [Accepted: 01/15/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unknown whether health related quality of life measured in German patients one year after mechanical ventilation in the intensive care unit is impaired or not. OBJECTIVES The aim of this study was to assess health related quality of life one year after inclusion into a randomized controlled trial for weaning from mechanical ventilation with the help of a questionnaire that has never been used in critically ill patients and to investigate whether health related quality of life scores differ between the study population and a general German population. METHODS We followed up with patients one year after inclusion into a randomized control trial investigating the effect of SmartCare/PS on total ventilation time compared to protocol-driven weaning (ASOPI trial, clinicaltrials.gov ID00445289). Health related quality of life was measured using the quality of life questionnaire C‑30 version 3.0 from the European Organization of Research and Treatment of Cancer (EORTC). Mean differences of at least 10 score points in the quality of life scales were considered clinically significant. RESULTS Of the 232 patients who were alive 90 days after study inclusion, 24 patients died one year after study inclusion and 64 patients were lost to follow-up. Of the remaining145 patients who were successfully contacted, 126 patients agreed to fill out the questionnaire. Questionnaires were sent back to the study site by 83 patients and these were analyzed. Health-related quality of life was significantly lower in five of the six functional scales (physical functioning, role functioning, cognitive functioning, social functioning, global health status) and in eight of the nine symptom scales (fatigue, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties) compared to the reference values of a German normal population. CONCLUSIONS The EORTC QLQ-C30 questionnaire is suitable for the acquisition of the health-related quality of life in formerly critically ill patients. Health-related quality of life is severely impaired after mechanical ventilation in the intensive care unit. Future studies should consider health related quality of life as a possible study endpoint.
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Affiliation(s)
- D Schädler
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland.
| | - L Kaiser
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland
| | - B Malchow
- Zentrum für Lebensqualität, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - T Becher
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland
| | - G Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland
| | - I Frerichs
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland
| | - T Küchler
- Zentrum für Lebensqualität, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - N Weiler
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 12, 24105, Kiel, Deutschland
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Phillips SM, Dickerson RN, Moore FA, Paddon-Jones D, Weijs PJM. Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient. Nutr Clin Pract 2017; 32:112S-120S. [PMID: 28388378 DOI: 10.1177/0884533616686719] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.
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Affiliation(s)
- Stuart M Phillips
- 1 McMaster University, Department of Kinesiology, Hamilton, Ontario, Canada
| | - Roland N Dickerson
- 2 Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Frederick A Moore
- 3 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Douglas Paddon-Jones
- 4 Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter J M Weijs
- 5 Nutrition and Dietetics, Department of Internal Medicine, Department of Intensive Care Medicine, and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands.,6 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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Heyland DK, Rooyakers O, Mourtzakis M, Stapleton RD. Proceedings of the 2016 Clinical Nutrition Week Research Workshop-The Optimal Dose of Protein Provided to Critically Ill Patients. JPEN J Parenter Enteral Nutr 2016; 41:208-216. [PMID: 28005459 DOI: 10.1177/0148607116682003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.
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Affiliation(s)
- Daren K Heyland
- 1 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Olav Rooyakers
- 2 Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.,3 Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marina Mourtzakis
- 4 Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Renee D Stapleton
- 5 Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington, Vermont, USA
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Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med 2016; 42:725-738. [PMID: 27025938 DOI: 10.1007/s00134-016-4321-8] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
Abstract
Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.
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Affiliation(s)
- Margaret S Herridge
- Critical Care and Respiratory Medicine, Toronto General Research Institute, University of Toronto, Toronto, ON, Canada.
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine L Hough
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ramona O Hopkins
- Psychology Department, Brigham Young University, Provo, UT, USA.,Neuroscience Center, Brigham Young University, Provo, UT, USA.,Department of Medicine, Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA.,Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Department of Medicine, Nashville, TN, USA
| | - O Joseph Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elie Azoulay
- Medical ICU of the Saint-Louis Hospital, Paris Diderot Sorbonne University, Paris, France
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