Can feeding strategies alter immune signaling and gut sepsis in critical illness?

Nutritional therapy for the prevention of post-intensive care syndrome

Post-intensive care syndrome (PICS) is a triad of physical, cognitive, and mental impairments that occur during or following the intensive care unit (ICU) stay, affecting the long-term prognosis of the patient and also the mental health of the patient's family. While the severity and duration of the systemic inflammation are associated with the occurrence of ICU-acquired weakness (ICU-AW), malnutrition and immobility during the treatment can exacerbate the symptoms. The goal of nutrition therapy in critically ill patients is to provide an adequate amount of energy and protein while addressing specific nutrient deficiencies to survive the inflammatory response and promote recovery from organ dysfunctions. Feeding strategy to prevent ICU-AW and PICS as nutrition therapy involves administering sufficient amounts of amino acids or proteins later in the acute phase after the hyperacute phase has passed, with specific attention to avoid energy overfeeding. Physiotherapy can also help mitigate muscle loss and subsequent physical impairment. However, many questions remain to be answered regarding the potential role and methods of nutrition therapy in association with ICU-AW and PICS, and further research is warranted.

Enteral nutrition in children and adolescents who receive extracorporeal membrane oxygenation and its impact on complications and mortality: A systematic review and meta-analysis

Enteral nutrition (EN) is one method of nutrition support for children and adolescents receiving extracorporeal membrane oxygenation (ECMO) therapy, and there are no guidelines for its use in this population. We conducted a systematic review to determine whether EN is effective and safe in children supported by ECMO. We searched the Cochrane Library database, MEDLINE, and Embase on Ovid in March 2023 to identify studies that evaluated children and adolescents who received ECMO and were treated with EN. Random effects meta-analysis was used to estimate the odds of mortality with EN compared with parenteral nutrition (PN). A total of 14 studies were included in this review with 1650 patients (796 received EN). The median duration of ECMO was 5-10 days, and the median EN initiation time ranged from 23 h to 7 days. The pooled results suggest no significant difference in mortality with EN compared with PN (odds ratio [OR] = 0.77; 95% CI, 0.56-1.05; I2 = 26%). Exclusion of the only study that reported an increase in mortality resulted in a borderline significant reduction in mortality with EN (OR = 0.71; 95% CI, 0.51-1.00; I2 = 26%). The predictors of EN were male sex, older age, heavier weight, greater height, cardiac diagnosis, longer duration of ECMO, and use of venovenous ECMO. Most studies suggest no correlation between EN and complications. EN use in children and adolescents who receive ECMO does not appear to be associated with increased mortality compared with PN and was safe in terms of intestinal complications and feeding intolerance.

Enteral nutrition in septic shock: a call for a paradigm shift

PURPOSE OF REVIEW

The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy.

RECENT FINDINGS

The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes.

SUMMARY

The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.

Quercetin Reduces Inflammation and Protects Gut Microbiota in Broilers

The aim of this study was to investigate the effects of quercetin on inflammatory response and intestinal microflora in broiler chicken jejuna. A total of 120 broiler chickens were allocated into 3 groups: saline-challenged broilers fed a basal diet (CTR group), lipopolysaccharide (LPS)-challenged broilers fed a basal diet (L group) and LPS-challenged broilers fed a basal diet supplemented with 200 mg/kg quercetin (LQ group). Our results showed that LPS significantly increased expression of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, interferon (IFN)-γ, toll-like receptor (TLR)-4, Bax, Caspase-3 and diamine oxidase activity (DAO), and decreased expression of zona occludens-1 (ZO-1), Occludin and Bcl-2 in the jejunum, while dietary quercetin prevented the adverse effects of LPS injection. LPS injection significantly decreased the number of Actinobacteria, Armatimonadetes and Fibrobacteriae at the phylum level when compared to the CTR group. Additionally, at genus level, compared with the CTR group, the abundance of Halomonas, Micromonospora, Nitriliruptor, Peptococcus, Rubellimicrobium, Rubrobacter and Slaclda in L group was significantly decreased, while dietary quercetin restored the numbers of these bacteria. In conclusion, our results demonstrated that dietary quercetin could alleviate inflammatory responses of broiler chickens accompanied by modulating jejunum microflora.