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Vira A, Roberts P, Preus R, Posey C, Miller S, Simmons J, Polite N, Bright A, Kinnard C, Williams A, Lee YL, Mbaka M. Management of Traumatic Duodenal Injury: Is There a Role for Early Parenteral Nutrition? J Surg Res 2024; 302:773-777. [PMID: 39216459 DOI: 10.1016/j.jss.2024.07.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/23/2024] [Accepted: 07/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Traumatic duodenal injuries are complex in nature and pose major challenges to trauma surgeons. These injuries are associated with high mortality rates ranging from 18% to 30% and require prompt, comprehensive care. Traumatic injury induces a hypercatabolic state that mobilizes body energy stores, leading to muscle wasting, delayed healing, and potential multi-organ failure. Nutritional support is vital in keeping up with the metabolic demands of traumatically injured patients. However, exactly when and how nutrition should be provided for traumatic duodenal injuries is unclear. We hypothesize that patients who sustain high-grade duodenal injuries (grades III-V) will be unable to tolerate enteral nutrition (EN) and may benefit from early initiation of total parenteral nutrition (TPN). METHODS In this retrospective chart review study, we queried the trauma registry for patients admitted between January 2018 and December 2022 with duodenal injury. Individuals under the age of 18 and individuals who were pregnant were excluded. Twenty-eight patients met the inclusion/exclusion criteria. The primary endpoint was median number of days from initial injury to supplemental nutrition. We also evaluated the route used to achieve adequate nutrition based on duodenal injury grade (I-V), mortality based on duodenal injury grade, morbidity based on route of nutrition supplementation (hospital length of stay [LOS], intensive care unit LOS, and ventilator days), and complications based on route of nutrition supplementation. RESULTS Of the 28 patients analyzed, 11 received EN, 10 received TPN (6 of which survived to transition to EN), and 7 died within 3 d of admission and did not receive any form of nutrition. The median number of days post-trauma to toleration of enteral feeding (defined as by mouth or tube feeding that meet total caloric needs based on nutritionist recommendations) was 4 d for those who did tolerate and maintained tolerance of enteral feeding, compared to 7.5 d post-trauma to initiate total parenteral feeding (P = 0.061). Injury grades I and II tolerated EN within a median of 6 d, whereas injury grades III and IV showed inability to tolerate EN until after a median of 22 d or longer (P = 0.02). Mortality increased as injury grade increased. Patients who received TPN were more likely to develop abscesses than those receiving EN (80% vs 27%, P = 0.03) but not more likely to develop a duodenal leak (P = 0.31). Patients who received TPN had longer hospital LOS (35.5 d vs 9 d, P = 0.008), longer intensive care unit LOS (17 d vs 4 d, P = 0.005), and increased ventilator days (9 d vs 1 d, P = 0.005) when compared to patients who received EN. CONCLUSIONS Individuals with higher grade duodenal injuries showed inability to tolerate EN until after a median of 22 d, and therefore, consideration should be given to initiating TPN early to mitigate the catabolic effects of malnutrition. Further studies need to be done with a larger number of patients to evaluate the effects of malnutrition in these patients.
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Affiliation(s)
- Anjali Vira
- University of South Alabama College of Medicine, Mobile, Alabama
| | - Priscilla Roberts
- General Surgery Resident, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Richard Preus
- University of South Alabama College of Medicine, Mobile, Alabama
| | - Connor Posey
- University of South Alabama College of Medicine, Mobile, Alabama
| | - Steven Miller
- Surgical Critical Care Fellow, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Jon Simmons
- Trauma/Emergency General Surgeon, Associate Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Nathan Polite
- Trauma/Emergency General Surgeon, Associate Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Andrew Bright
- Trauma/Emergency General Surgeon, Associate Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Christopher Kinnard
- Trauma/Emergency General Surgeon, Associate Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Ashley Williams
- Trauma/Surgical Critical Care, Assistant Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Yann-Leei Lee
- Trauma/Surgical Critical Care, Assistant Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama
| | - Maryann Mbaka
- Trauma/Emergency General Surgeon, Associate Professor of Surgery, University Hospital, University of South Alabama College of Medicine, Mobile, Alabama.
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Haines KL, Walsh J, Sytsma T, Tiko-Okoye C, Molinger J, Howell S, Agarwal S, Vatsaas C, Cox CE, Schmader K, Wischmeyer PE. Predictive Energy Equations Inaccurately Estimate Metabolic Demands of Older Adult Trauma Patients. J Surg Res 2024; 302:525-532. [PMID: 39178568 DOI: 10.1016/j.jss.2024.07.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 07/09/2024] [Accepted: 07/19/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Suboptimal nutrition promotes unfavorable outcomes in trauma patients, particularly among those aged 60 and over. While many institutions employ predictive energy equations to determine patients' energy requirements, mounting evidence shows these equations inaccurately estimate caloric needs. In this pilot randomized controlled trial, we sought to quantify the discrepancy between predictive equations and indirect calorimetry (IC)-the gold standard for determining energy requirements-in the older adult trauma population. METHODS This is a nested cohort study within a pilot randomized control trial in which 32 older adult trauma patients were randomized 3:1 to receive IC-guided nutrition delivery versus standard of care. IC requirements of patients in the intervention arm were compared to Mifflin St. Jeor (MSJ), Harris-Benedict (HB), and the American Society for Parenteral and Enteral Nutrition-Society of Critical Care Medicine (ASPEN-SCCM) predictive energy equations. RESULTS Twenty patients underwent IC to assess measured resting energy expenditure (mREE), yielding a mean (standard deviation) mREE of 23.1 ± 4.8 kcal/kg/d. MSJ and HB gave mean predictive resting energy expenditures of 17.5 ± 2.0 and 18.5 ± 2.0 kcal/kg/d in these patients, demonstrating that IC-derived values were 32.1% and 25.0% higher, respectively. When patients were stratified by body mass index (BMI), MSJ, and HB more severely underestimated caloric requirements in individuals with BMI <30 versus BMI 30-50. While the mean mREE fell within the mean predictive resting energy expenditure range prescribed by ASPEN-SCCM equations (21.4 ± 4.1 to 26.2 ± 4.3 kcal/kg/d), individuals' IC-derived values fell within their personal range in 8 of 20 cases. CONCLUSIONS The MSJ and HB predictive energy equations consistently and significantly underpredict metabolic demands of older adult trauma patients compared to IC and perform worse in lower BMI individuals. ASPEN-SCCM equations frequently overpredict or underpredict resting energy expenditure. While these findings should be confirmed in a larger randomized control trial, this study suggests that institutions should prioritize IC to accurately identify the metabolic demands of older trauma patients.
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Affiliation(s)
- Krista L Haines
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina; Department of Anesthesiology, Division of Critical Care, Human Pharmacology and Physiology Laboratory (HPPL), Duke University School of Medicine, Durham, North Carolina.
| | - Julie Walsh
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Trevor Sytsma
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Chidinma Tiko-Okoye
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jeroen Molinger
- Department of Anesthesiology, Division of Critical Care, Human Pharmacology and Physiology Laboratory (HPPL), Duke University School of Medicine, Durham, North Carolina
| | - Shauna Howell
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Suresh Agarwal
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Cory Vatsaas
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Christopher E Cox
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ken Schmader
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, and GRECC, Durham VA Health Care System, Durham, North Carolina
| | - Paul E Wischmeyer
- Department of Surgery, Division of Trauma, Acute, and Critical Care Surgery, Duke University School of Medicine, Durham, North Carolina; Department of Anesthesiology, Division of Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
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van Ee EPX, Verheul EAH, Dijkink S, Krijnen P, Veldhuis W, Feshtali SS, Avery L, Lucassen CJ, Mieog SD, Hwabejire JO, Schipper IB. The correlation of CT-derived muscle density, skeletal muscle index, and visceral adipose tissue with nutritional status in severely injured patients. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02624-6. [PMID: 39167212 DOI: 10.1007/s00068-024-02624-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND This study explored if computerized tomography-derived body composition parameters (CT-BCPs) are related to malnutrition in severely injured patients admitted to the Intensive Care Unit (ICU). METHODS This prospective cohort study included severely injured (Injury Severity Score ≥ 16) patients, admitted to the ICU of three level-1 trauma centers between 2018 and 2022. Abdominal CT scans were retrospectively analyzed to assess the CT-BCPs: muscle density (MD), skeletal muscle index (SMI), and visceral adipose tissue (VAT). The Subjective Global Assessment was used to diagnose malnutrition at ICU admission and on day 5 of admission, and the modified Nutrition Risk in Critically ill at admission was used to assess the nutritional risk. RESULTS Seven (11%) of the 65 analyzed patients had malnutrition at ICU admission, increasing to 23 patients (35%) on day 5. Thirteen (20%) patients had high nutritional risk. CT-BCPs were not related to malnutrition at ICU admission and on day 5. Patients with high nutritional risk at admission had lower MD (median (IQR) 32.1 HU (25.8-43.3) vs. 46.9 HU (37.7-53.3); p < 0.01) and higher VAT (median 166.5 cm2 (80.6-342.6) vs. 92.0 cm2 (40.6-148.2); p = 0.01) than patients with low nutritional risk. CONCLUSION CT-BCPs do not seem related to malnutrition, but low MD and high VAT may be associated with high nutritional risk. These findings may prove beneficial for clinical practice, as they suggest that CT-derived parameters may provide valuable information on nutritional risk in severely injured patients, in addition to conventional nutritional assessment and screening tools. LEVEL OF EVIDENCE Level III, Prognostic/Epidemiological.
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Affiliation(s)
- Elaine P X van Ee
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R|, P.O. Box 9600, Leiden, 2300 RC, The Netherlands.
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Esmee A H Verheul
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R|, P.O. Box 9600, Leiden, 2300 RC, The Netherlands
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R|, P.O. Box 9600, Leiden, 2300 RC, The Netherlands
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R|, P.O. Box 9600, Leiden, 2300 RC, The Netherlands
- Acute Care Network West Netherlands, Leiden, the Netherlands
| | - Wouter Veldhuis
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shirin S Feshtali
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Laura Avery
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Claudia J Lucassen
- Department of Dietetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - John O Hwabejire
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R|, P.O. Box 9600, Leiden, 2300 RC, The Netherlands
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Verheul EA, Horzum E, Dijkink S, Krijnen P, Hoogendoorn JM, Arbous SM, Peters R, Schipper IB. Fat-soluble vitamins as biomarkers of nutritional status and their relation with complications in polytrauma patients. Nutr Health 2024:2601060241273640. [PMID: 39155642 DOI: 10.1177/02601060241273640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
BACKGROUND AND AIMS This exploratory observational prospective study aimed to evaluate fat-soluble vitamin plasma levels during hospital admission and its relation with the development of malnutrition and complications in polytrauma patients, considering the protocolized multivitamin supplementation during intensive care unit (ICU) admission. METHODS In 49 well-nourished polytrauma (injury severity score ≥ 16) patients admitted to the ICU of two level-1 trauma centers, vitamin A, D, and E levels were assessed weekly during hospital stay. All patients received multivitamin supplementation during ICU stay. Linear mixed-effect models were used to assess a trend in vitamin levels over time during hospital stay. Mixed-effects logistic regression analysis was performed to relate vitamin concentrations with malnutrition, defined as a subjective global assessment score ≤5, and complications. RESULTS Vitamin A levels increased 0.17 µmol/L per week (95% confidence interval 0.12-0.22, p < 0.001), vitamin D levels increased 1.49 nmol/L per week (95% confidence interval 0.64-2.33, p < 0.01), vitamin E levels increased 1.17 µmol/L per week (95% confidence interval 0.61-1.73, p < 0.001) during hospital stay (29 ± 17 days). Vitamin levels were not related to malnutrition or complications during hospital stay. CONCLUSION Vitamin A, D, and E levels increased due to supplementation during hospital admission. Plasma levels of vitamins A, D, and E do not seem to be useful as biomarkers for the nutritional status of polytrauma patients during hospital stay. No correlation with complications could be demonstrated.
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Affiliation(s)
- Esmee Ah Verheul
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ebru Horzum
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Department of General Surgery, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Acute Care Network West Netherlands, Leiden, The Netherlands
| | - Jochem M Hoogendoorn
- Department of General Surgery, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Sesmu M Arbous
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ron Peters
- Department of Intensive Care, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Hosseinpour H, Anand T, Bhogadi SK, Nelson A, Hejazi O, Castanon L, Ghaedi A, Khurshid MH, Magnotti LJ, Joseph B. The implications of poor nutritional status on outcomes of geriatric trauma patients. Surgery 2024:S0039-6060(24)00471-9. [PMID: 39060117 DOI: 10.1016/j.surg.2024.06.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/26/2024] [Accepted: 06/13/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status. METHODS This is a secondary analysis of the prospective observational American Association of Surgery for Trauma Frailty Multi-institutional Trial. Geriatric (≥65 years) patients presenting to 1 of the 17 Level I/II/III trauma centers (2019-2021) were included and stratified using the simplified Geriatric Nutritional Risk Index (albumin [g/dL] + body mass index [kg/m2]/10) into severe (simplified Geriatric Nutritional Risk Index <5), moderate (5.5> simplified Geriatric Nutritional Risk Index ≥5), mild level of nutritional risk (6> simplified Geriatric Nutritional Risk Index ≥5.5), and good nutritional status (simplified Geriatric Nutritional Risk Index ≥6) and compared. RESULTS Of the 1,321 patients enrolled, 22% were at risk of poor nutritional status (mild: 13%, moderate: 7%, severe: 3%). The mean age was 77 ± 8 years, and the median [interquartile range] Injury Severity Score was 9 [5-13]. Patients at risk of poor nutritional status had greater rates of sepsis, pneumonia, discharge to the skilled nursing facility and rehabilitation center, index-admission mortality, and 3-month mortality (P < .05). On multivariable analyses, being at risk of severe level of nutritional risk was independently associated with sepsis (adjusted odds ratio 6.21, 95% confidence interval 1.68-22.90, P = .006), pneumonia (adjusted odds ratio 4.40, 95% confidence interval 1.21-16.1, P = .025), index-admission mortality (adjusted odds ratio 3.16, 95% confidence interval 1.03-9.68, P = .044), and 3-month mortality (adjusted odds ratio 8.89, 95% confidence interval 2.01-39.43, P = .004) compared with good nutrition state. CONCLUSION Nearly one quarter of geriatric trauma patients were at risk of poor nutritional status, which was identified as an independent predictor of worse index admission and 3-month postdischarge outcomes. These findings underscore the need for nutritional screening at admission.
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Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Adam Nelson
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Omar Hejazi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Lourdes Castanon
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Arshin Ghaedi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Muhammad Haris Khurshid
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ.
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Hagedorn A, Haberl H, Adamzik M, Wolf A, Unterberg M. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 2 - Secondary Treatment Strategies, Long-term Outcome, Neuroprognostics and Chronification]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:466-478. [PMID: 39074791 DOI: 10.1055/a-2332-1423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
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Mizuochi M, Yamaguchi J, Chiba N, Kinoshita K. Patients with Severe Trauma Having an Injury Severity Score of 24 and above Develop Nutritional Disorders. Diagnostics (Basel) 2024; 14:1307. [PMID: 38928722 PMCID: PMC11202517 DOI: 10.3390/diagnostics14121307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/08/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
In this single-center, retrospective, observational study, we aimed to assess the severity at which patients with trauma tend to develop metabolic disturbances that worsen their Controlling Nutritional Status (CONUT) scores. Participants were general adult patients with trauma hospitalized for at least one week. Injury Severity Scores (ISSs) at admission and CONUT scores one week later were calculated, and correlation coefficients were examined. The receiver operating characteristic (ROC) curve was used to calculate the ISS cutoff value for a CONUT score of 5 or more on day 7 of hospitalization. The ISS was assessed using multiple logistic regression analysis to determine whether it predicts worse nutritional status. Forty-nine patients were included. ISSs correlated with CONUT scores on day 7 (r = 0.373, p = 0.008). Using the ROC curve, the cutoff value for the ISS was 23.5. Multiple logistic regression analyses showed that a high ISS (odds ratio [OR], 1.158; 95% confidence interval [CI], 1.034-1.296; p = 0.011) and older age (OR, 1.094; 95% CI, 1.027-1.165; p = 0.005) were associated with a CONUT score 5 or more on day 7 of hospitalization. Patients with trauma with an ISS of 24 or higher have worsening CONUT scores during hospitalization; these patients require careful nutritional management.
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Affiliation(s)
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan; (M.M.); (N.C.); (K.K.)
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Poblete RA, Pena J, Kuo G, Tarzi F, Nguyen PL, Cen SY, Yaceczko S, Louie SG, Lewis MR, Martin M, Amar AP, Sanossian N, Sung G, Lyden PD. Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes. Neurotrauma Rep 2024; 5:574-583. [PMID: 39036427 PMCID: PMC11257118 DOI: 10.1089/neur.2024.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and proimmune properties; however, their use has not been rigorously studied in human TBI populations. A single-center, retrospective, descriptive observational study was conducted at the LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared with those who received standard, polymeric EN with regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.
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Affiliation(s)
- Roy A. Poblete
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jesus Pena
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Grace Kuo
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Fawaz Tarzi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Peggy L. Nguyen
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Steven Y. Cen
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Shelby Yaceczko
- UCLA Health, University of California, Los Angeles, California, USA
| | - Stan G. Louie
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, California, USA
| | - Meghan R. Lewis
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Matthew Martin
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Arun P. Amar
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Gene Sung
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Patrick D. Lyden
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, USA
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Bayuo J, Pwara J, Davids J, Agbeko AE, Agbenorku P, Hoyte-Williams PE. Nutrition education programs for burn survivors: A scoping review. Nutr Health 2024; 30:199-205. [PMID: 37728147 DOI: 10.1177/02601060231203282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Background: Despite the importance of nutrition education for burn survivors, only limited work has been done to ascertain what is known about these education programs. Aim: To scope the existing literature to ascertain what is known about the nature and outcomes associated with nutrition education programs for burn survivors, their families and caregivers. Methods: Arksey and O'Malley scoping review approach were utilized with searches across peer-reviewed databases and gray literature sources. Results: Six studies were retained. Five studies focused on burn survivors and one focused on healthcare professionals. One study reported improved knowledge regarding postburn nutritional support following the implementation of the nutrition counseling program. Three studies reported on the inclusion of a nutrition education component in comprehensive postdischarge rehabilitation programs albeit no nutrition-specific outcomes were reported. Conclusion: The review affirms the limited literature, highlighting a need for more work to implement and evaluate outcomes of nutrition education programs for burn survivors.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing and Midwifery, Presbyterian University, Agogo, Ghana
| | - Joyce Pwara
- School of Nursing and Midwifery, University of Ghana, Legon, Ghana
| | - Jephtah Davids
- Department of Nutrition, University of Ghana, Legon, Ghana
| | | | - Pius Agbenorku
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Division of Plastic and Reconstructive Surgery, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Paa Ekow Hoyte-Williams
- Division of Plastic and Reconstructive Surgery, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Hartwell JL, Evans DC, Martin MJ. Nutritional support for the trauma and emergency general surgery patient: What you need to know. J Trauma Acute Care Surg 2024; 96:855-864. [PMID: 38409684 DOI: 10.1097/ta.0000000000004283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
ABSTRACT Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Jennifer L Hartwell
- From the Division of Acute Care Surgery, Department of Surgery (J.L.H.), University of Kansas Medical Center, Kansas Center, Kansas; Department of Surgery (D.C.E.), Ohio University, OhioHealth Grant Medical Center, Columbus, Ohio; and Division of Trauma and Surgical Critical Care (M.J.M.), Los Angeles County + USC Medical Center, Los Angeles, California
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Weiss MB, Syed SA, Whiteson HZ, Hirani R, Etienne M, Tiwari RK. Navigating Post-Traumatic Osteoporosis: A Comprehensive Review of Epidemiology, Pathophysiology, Diagnosis, Treatment, and Future Directions. Life (Basel) 2024; 14:561. [PMID: 38792583 PMCID: PMC11122478 DOI: 10.3390/life14050561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/14/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Post-traumatic osteoporosis (PTO) presents a significant challenge in clinical practice, characterized by demineralization and decreased skeletal integrity following severe traumatic injuries. This literature review manuscript addresses the knowledge gaps surrounding PTO, encompassing its epidemiology, pathophysiology, risk factors, diagnosis, treatment, prognosis, and future directions. This review emphasizes the complexity of the etiology of PTO, highlighting the dysregulation of biomineralization processes, inflammatory cytokine involvement, hormonal imbalances, glucocorticoid effects, vitamin D deficiency, and disuse osteoporosis. Moreover, it underscores the importance of multidisciplinary approaches for risk mitigation and advocates for improved diagnostic strategies to differentiate PTO from other musculoskeletal pathologies. This manuscript discusses various treatment modalities, including pharmacotherapy, dietary management, and physical rehabilitation, while also acknowledging the limited evidence on their long-term effectiveness and outcomes in PTO patients. Future directions in research are outlined, emphasizing the need for a deeper understanding of the molecular mechanisms underlying PTO and the evaluation of treatment strategies' efficacy. Overall, this review provides a comprehensive overview of PTO and highlights avenues for future investigation to enhance clinical management and patient outcomes.
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Affiliation(s)
- Matthew B. Weiss
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
| | - Shoaib A. Syed
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
| | - Harris Z. Whiteson
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
| | - Rahim Hirani
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
- Graduate School of Biomedical Sciences, New York Medical College, Valhalla, NY 10595, USA
| | - Mill Etienne
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
| | - Raj K. Tiwari
- School of Medicine, New York Medical College, Valhalla, NY 10595, USA (H.Z.W.); (R.H.); (M.E.)
- Graduate School of Biomedical Sciences, New York Medical College, Valhalla, NY 10595, USA
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Tedesco A, Sharma AK, Acharya N, Rublev G, Hashmi S, Wu HH, Lee YP, Scolaro J, Bhatia N. The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes. JBJS Rev 2024; 12:01874474-202404000-00004. [PMID: 38619394 DOI: 10.2106/jbjs.rvw.23.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.
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Affiliation(s)
- Amanda Tedesco
- School of Medicine, University of California, Irvine, Irvine, California
| | - Abhinav K Sharma
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nischal Acharya
- School of Medicine, University of California, Irvine, Irvine, California
| | - George Rublev
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Sohaib Hashmi
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Hao-Hua Wu
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Yu-Po Lee
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - John Scolaro
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Nitin Bhatia
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
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Elks W, McNickle AG, Kelecy M, Batra K, Wong S, Wang S, Angotti L, Kuhls DA, St Hill C, Saquib SF, Chestovich PJ, Fraser DR. Early Versus Late Feeding After Percutaneous Endoscopic Gastrostomy Placement in Trauma and Burn. J Surg Res 2024; 295:112-121. [PMID: 38006778 DOI: 10.1016/j.jss.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/13/2023] [Accepted: 10/28/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Timing to resume feeds after percutaneous endoscopic gastrostomy (PEG) placement continues to vary among US trauma surgeons. The purpose of this study was to assess differences in meeting nutritional therapy goals and adverse outcomes with early versus late enteral feeding after PEG placement. METHODS This retrospective review included 364 trauma and burn patients who underwent PEG placement. Data included patient characteristics, time to initiate feeds, rate feeds were resumed, % feed volume goals on postoperative days 0-7, and complications. Statistical analysis was performed comparing two groups (feeds ≤ 6 h versus > 6 h) and three subgroups (< 4 h, 4-6 h, ≥ 6 h) based on data quartiles. Chi-square/Fisher's exact test, independent-samples t-test, and one-way analysis of variance were used to analyze the data. RESULTS Mean time to initiate feeds after PEG was 5.48 ± 4.79 h. Burn patients received early feeds in a larger proportion. A larger proportion of trauma patients received late feeds. The mean % of goal feed volume met on postoperative day 0 was higher in the early feeding group versus the late (P < 0.001). There were no differences in adverse events, even after subgroup analysis of those who received feeds < 4 h after PEG placement. CONCLUSIONS Patients with early initiation of feeds after PEG placement achieve a higher percentage of goals on day 0 without an increased rate of adverse events. Unfortunately, patients routinely fall short of their target tube feeding goals.
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Affiliation(s)
- Whitney Elks
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada.
| | - Allison G McNickle
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Matthew Kelecy
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Kavita Batra
- Department of Medical Education, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Shirley Wong
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Shawn Wang
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Lisa Angotti
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Deborah A Kuhls
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Charles St Hill
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Syed F Saquib
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Paul J Chestovich
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
| | - Douglas R Fraser
- Department of Surgery, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, Las Vegas, Nevada
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Gouhari F, Zandi R, Mehrvar A, Talebi S, Vahdat Shariatpanahi Z. Improved physical disability and nutritional status by bovine colostrum supplementation in adults with traumatic peri-trochanteric femoral fracture: A randomized, controlled, clinical trial. Injury 2024; 55:111253. [PMID: 38042695 DOI: 10.1016/j.injury.2023.111253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/26/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVES Patients with femur fracture after surgery are at risk of malnutrition, weight loss, disability, and mobility complications. In the present study the role of colostrum supplementation on physical disability, and some nutritional variables after surgery has been investigated. RESEARCH METHODS & PROCEDURES Patients were randomly assigned to two groups. The intervention group received 45 g colostrum and the control group received 15 g whey protein daily for 21 days (each containing 12 g of protein). The trend comparison during 30 days of variables including weight, appetite, serum albumin level, hemoglobin and lymphocytes between the two groups was modeled with the generalized estimation equation. Moreover, the trend comparison during 90 days of Oswestry Disability Index (ODI) between the two groups was calculated. RESULTS The basic characteristics were the same between the two groups (colostrum, n = 46; control, n = 48). Protein intake was the same in both groups during the study period. There was a significant difference in weight gain (ß = 0.32, 95 % CI: 0.09-0.54; P = 0.005) within 30 days after operation between the colostrum and control groups in favor of the increase in the colostrum group. Compared to the control group, patients in the colostrum group had a 0.31 score more appetite (P < 0.001), 0.17 g/dL higher serum albumin level (P = 0.001), 0.5 mg/dL higher hemoglobin level and 440 more blood lymphocytes (P < 0.001) during the 30 days of intervention. Regarding physical function disability, patients in the colostrum group had about 4 ODI scores lower than the control group during the study period. CONCLUSION Colostrum supplement can increase appetite, hemoglobin, serum albumin level and the number of blood lymphocytes more than the control group. It can also accelerate weight gain and physical performance after surgery.
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Affiliation(s)
- Faezeh Gouhari
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Zandi
- Department of Orthopedics, Taleghani Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Mehrvar
- Department of Orthopedics, Taleghani Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Talebi
- Department of Orthopedics, Taleghani Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Vahdat Shariatpanahi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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15
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Carlson JP, Peña K, Burjonrappa S. The Obesity Paradox in the Pediatric Trauma Patient. J Pediatr Surg 2024; 59:275-280. [PMID: 37993398 DOI: 10.1016/j.jpedsurg.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Obesity is a chronic disease that adversely impacts patient outcomes and increasingly affecting the pediatric population. According to the CDC, in 2020 the prevalence of obesity among children and adolescents was estimated to be as high as 19.7%. The obesity paradox is the increased survival for overweight and obese adult trauma patients when compared to patients with healthy weights. The aim of this study was to analyze the impact of BMI and outcomes in the pediatric trauma population. METHODS Trauma patients in the 2-18 years age group and reported to the 2017-2019 National Trauma Data Bank were identified. CDC growth charts and z-scores were calculated to categorize patients into four subgroups: underweight (<5th percentile), healthy weight (5th-85th percentile), overweight (85th-95th percentile), and obesity (>95th percentile). Primary outcome studied was the mortality rate. Secondary outcomes included injury severity score (ISS), hospital length of stay (LOS), ICU LOS, and number of days on a ventilator. Continuous and categorical data were analyzed using ANOVA and Chi-squared test, respectively, using the healthy BMI category as reference group. P < 0.05 was considered significant. RESULTS A total of 161,458 patients [Underweight: 9148 (6%), Healthy weight: 88,009 (55%), Overweight: 26,740 (17%), and Obese: 37,561 (23%)] were included. The mean age was 11 years (SD:5.1). Total mortality for the patient set was 1825 (1.13%). The lowest mortality rate was in the obese group. The ISS was lowest in the obese group, while ICU LOS and days on ventilator were no different than control patients. Hospital LOS and transfer to rehabilitation rates were higher in the obese population. CONCLUSION Obesity appears to have a protective effect on mortality and significantly better secondary outcomes in the pediatric trauma population. Further study is necessary to evaluate the interplay between body weight and outcomes in pediatric trauma and disease states. LEVEL OF EVIDENCE III.
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Gorenshtein L, Leraas H, Eze A, Lumpkin S, Chime C, Chang D, Wischmeyer P, Agarwal S, Fernandez J, Haines KL. The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury. J Surg Res 2024; 293:121-127. [PMID: 37738853 DOI: 10.1016/j.jss.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.
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Affiliation(s)
| | - Harold Leraas
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Anthony Eze
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Chinecherem Chime
- School of Medicine, Howard University College of Medicine, Washington, District of Columbia
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, North Carolina
| | - Paul Wischmeyer
- Department of Surgery, Duke University, Durham, North Carolina
| | - Suresh Agarwal
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina
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Thomas D, Kamalumpundi V, Thampi A, Lockman K, Carter MB, Vidwan N, Broderick A. Antibiotic stewardship in Indian palliative care: a single-center retrospective study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e196. [PMID: 38028900 PMCID: PMC10654949 DOI: 10.1017/ash.2023.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023]
Abstract
Objective Characterize antibiotic prescribing behaviors at an Indian palliative care center after the initiation of the Antibiotic Order Form (AOF): an antibiotic stewardship program involving a paper form to track antibiotic use and to provide prescription guidelines. Design Retrospective chart review. Setting Trivandrum Institute of Palliative Sciences (TIPS) is a palliative care organization in Kerala, India. Methods Antibiotic prescription data and patient data were collected for adult patients treated at TIPS between January 1, 2017, and October 31, 2019. Descriptive statistics and a Zero-Inflated Poisson regression model were used to analyze antibiotic prescriptions. AOF completion and prescription concordance with institutional guidelines were also evaluated. Results Out of 7,450 unique patients, 675 (9%) were prescribed 1,448 antibiotics. Age was the strongest factor in determining the number of antibiotic courses with each additional year of age decreasing the expected antibiotic prescription count by 2% per year. The most common antibiotics prescribed were topical metronidazole (44%) and penicillins (29%). Among patients who died, 5% were prescribed antibiotics within the final month of life. In total, 32% of antibiotic prescriptions were documented in AOFs, and 18% were concordant with all institutional antibiotic prescribing guidelines. Conclusions This study is the first to analyze an antibiotic stewardship intervention in a palliative care setting within a low- and middle-income country. This retrospective study provides a benchmark of antibiotic use within Indian palliative care and highlights areas for future stewardship research including topical metronidazole use within palliative care and higher rates of antibiotic use among younger palliative care patients.
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Affiliation(s)
- David Thomas
- University of Louisville, School of Medicine, Louisville, KY, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Mary B. Carter
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - Navjyot Vidwan
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - Ann Broderick
- Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Iowa City VA Medical Center, Iowa City, IA, USA
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Poblete RA, Pena JE, Kuo G, Tarzi F, Nguyen PL, Cen SY, Yaceczko S, Louie SG, Lewis MR, Martin M, Amar AP, Sanossian N, Sung G, Lyden PD. Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes. RESEARCH SQUARE 2023:rs.3.rs-3548036. [PMID: 37986931 PMCID: PMC10659558 DOI: 10.21203/rs.3.rs-3548036/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations. Methods A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. Results A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. Conclusion This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.
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Affiliation(s)
- Roy A Poblete
- University of Southern California Keck School of Medicine
| | - Jesus E Pena
- University of Southern California Keck School of Medicine
| | - Grace Kuo
- University of Southern California Keck School of Medicine
| | - Fawaz Tarzi
- University of Southern California Keck School of Medicine
| | - Peggy L Nguyen
- University of Southern California Keck School of Medicine
| | - Steven Y Cen
- University of Southern California Keck School of Medicine
| | - Shelby Yaceczko
- University of California Los Angeles Health System: UCLA Health
| | - Stan G Louie
- University of Southern California School of Pharmacy
| | - Meghan R Lewis
- University of Southern California Keck School of Medicine
| | - Matthew Martin
- University of Southern California Keck School of Medicine
| | - Arun P Amar
- University of Southern California Keck School of Medicine
| | | | - Gene Sung
- University of Southern California Keck School of Medicine
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Sparling JL, Nagrebetsky A, Mueller AL, Albanese ML, Williams GW, Wischmeyer PE, Rice TW, Low YH. Preprocedural fasting policies for patients receiving tube feeding: A national survey. JPEN J Parenter Enteral Nutr 2023; 47:1011-1020. [PMID: 37543845 DOI: 10.1002/jpen.2556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures. METHODS The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated. RESULTS The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed. CONCLUSIONS Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.
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Affiliation(s)
- Jamie L Sparling
- Department of Anesthesia, Critical Care, & Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexander Nagrebetsky
- Department of Anesthesia, Critical Care, & Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ariel L Mueller
- Department of Anesthesia, Critical Care, & Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marissa L Albanese
- Department of Anesthesia, Critical Care, & Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George W Williams
- Department of Anesthesiology, Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ying H Low
- Department of Anesthesia, Critical Care, & Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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Li P, Li S, Liu S, Li M. Modified Nutrition Risk in the Critically ill score and mortality in critically ill patients with traumatic brain injury. Nutr Clin Pract 2023; 38:1032-1044. [PMID: 37255501 DOI: 10.1002/ncp.11014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Understanding the relationship between nutrition risk at admission to the intensive care unit (ICU) and the prognosis of patients with traumatic brain injury (TBI) may aid early recognition of high-risk patients. METHODS We extracted data from the Medical Information Mart for Intensive Care III and the electronic ICU Collaborative Research Databases. Using modified Nutrition Risk in the Critically ill score (mNUTRIC) within the first 24 h of ICU admission, 5153 patients were divided into three groups: low (≤1, n = 1765), moderate (2-4, n = 2574), and high (≥5, n = 814). The primary outcome was 28-day in-hospital mortality, and the secondary outcomes were 7-day in-hospital mortality, length of ICU stay, and duration of mechanical ventilation. RESULTS During the median follow-up time of 6.69 days, 647 deaths occurred in total. After adjustment for potential confounding factors, setting the low mNUTRIC group as a reference, the risk of 28-day mortality was increased in the high and moderate mNUTRIC groups (hazard ratio [HR]high vs low [95% CI]: 4.21 [2.70-6.58] and 2.84 [1.95-4.14], respectively). Similarly, high and moderate mNUTRIC scores are linked to a higher risk of 7-day mortality (PTrend < 0.001) and a longer duration of mechanical ventilation (PTrend < 0.001). The effect of mNUTRIC on mortality varied by serum glucose level (PInteraction = 0.01). Lastly, those whose mNUTRIC scores deteriorated within the first 3 days have a 1.46 times greater risk of dying compared with patients with improved mNUTRIC scores. CONCLUSIONS Nutrition risk screening by mNUTRIC score at the time of admission to the ICU may improve mortality prediction.
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Affiliation(s)
- Ping Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Sikai Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Shanshan Liu
- Department of Critical Illness, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Man Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
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21
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Poblete RA, Yaceczko S, Aliakbar R, Saini P, Hazany S, Breit H, Louie SG, Lyden PD, Partikian A. Optimization of Nutrition after Brain Injury: Mechanistic and Therapeutic Considerations. Biomedicines 2023; 11:2551. [PMID: 37760993 PMCID: PMC10526443 DOI: 10.3390/biomedicines11092551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Emerging science continues to establish the detrimental effects of malnutrition in acute neurological diseases such as traumatic brain injury, stroke, status epilepticus and anoxic brain injury. The primary pathological pathways responsible for secondary brain injury include neuroinflammation, catabolism, immune suppression and metabolic failure, and these are exacerbated by malnutrition. Given this, there is growing interest in novel nutritional interventions to promote neurological recovery after acute brain injury. In this review, we will describe how malnutrition impacts the biomolecular mechanisms of secondary brain injury in acute neurological disorders, and how nutritional status can be optimized in both pediatric and adult populations. We will further highlight emerging therapeutic approaches, including specialized diets that aim to resolve neuroinflammation, immunodeficiency and metabolic crisis, by providing pre-clinical and clinical evidence that their use promotes neurologic recovery. Using nutrition as a targeted treatment is appealing for several reasons that will be discussed. Given the high mortality and both short- and long-term morbidity associated with acute brain injuries, novel translational and clinical approaches are needed.
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Affiliation(s)
- Roy A. Poblete
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Shelby Yaceczko
- UCLA Health, University of California, 100 Medical Plaza, Suite 345, Los Angeles, CA 90024, USA;
| | - Raya Aliakbar
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Pravesh Saini
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Saman Hazany
- Department of Radiology, Keck School of Medicine, The University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA;
| | - Hannah Breit
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Stan G. Louie
- Department of Clinical Pharmacy, School of Pharmacy, The University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90089, USA;
| | - Patrick D. Lyden
- Department of Neurology, Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA;
| | - Arthur Partikian
- Department of Neurology, Department of Pediatrics, Keck School of Medicine, The University of Southern California, 2010 Zonal Avenue, Building B, 3P61, Los Angeles, CA 90033, USA;
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22
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Al-Thani H, Wahlen BM, El-Menyar A, Asim M, Nassar LR, Ahmed MN, Nabir S, Mollazehi M, Abdelrahman H. Acute Changes in Body Muscle Mass and Fat Depletion in Hospitalized Young Trauma Patients: A Descriptive Retrospective Study. Diseases 2023; 11:120. [PMID: 37754316 PMCID: PMC10528496 DOI: 10.3390/diseases11030120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Background: Loss of muscle mass, and its strength, is associated with adverse outcomes in many medical and surgical conditions. Trauma patients may get malnourished during their hospital course due to many interrelated contributing factors. However, there is insufficient knowledge on the acute muscle and fat changes in young trauma patients in the early days post-admission. Objective: to explore the diagnosis, feeding status, and outcome of muscle mass loss among young abdominal polytrauma patients. Methods: It was a retrospective study including hospitalized abdominal trauma patients who underwent an abdominal computerized tomographic (CT) examination initially and a follow-up one week later. CT scan-based automatic and manual analysis of the muscles and fat of the abdominal region was calculated and compared. Also, we evaluated the feeding and nutritional values to explore the adequacy of the provided calories and proteins and the potential influence of enteral feeding on the CT-based parameters for muscle loss and fat depletion. Results: There were 138 eligible subjects with a mean age of 32.8 ± 13.5 years; of them, 92% were males. Operative interventions were performed on two-thirds of the patients, including abdominal surgery (43%), orthopedic surgeries (34%), and neurosurgical procedures (8.1%). On admission, 56% received oral feeding, and this rate slightly increased to 58.4% after the first week. Enteral feed was prescribed for the remaining, except for two patients. The percentage of change in the total psoas muscle area was significantly reduced after one week of admission in patients on enteral feed as compared to those in the oral feeding group (p = 0.001). There were no statistically significant differences in the percentages of changes in the CT scan findings except for the total psoas muscle area (p = 0.001) and para-spinal muscle area (p = 0.02), which reduced significantly in the those who underwent laparotomy as compared to those who did not need laparotomy. Trauma patients who underwent emergency abdominal surgery lost muscle and fat over time. Conclusions: Loss of muscle mass and body fat is not uncommon among young trauma patients. Patients who underwent laparotomy are more likely to be affected. Further larger studies are needed to assess the specific features in the younger trauma population and how far this can be influenced by the nutrition status and its impact on the clinical outcomes. It could be early or impending stages of sarcopenia linked to trauma patients, or just acute changes in the muscle and fat, that need further investigation and follow-up after hospital discharge.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma & Vascular Surgery, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Bianca M. Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery Section, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
- Department of Clinical Medicine, Weill Cornell Medicine, Doha P.O. Box 24144, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery Section, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Lena Ribhi Nassar
- Department of Dietetics and Nutrition, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Mohamed Nadeem Ahmed
- Department of Radiology, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar; (M.N.A.); (S.N.)
| | - Syed Nabir
- Department of Radiology, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar; (M.N.A.); (S.N.)
| | - Monira Mollazehi
- Trauma Registry, Trauma Surgery, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar;
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23
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Nwafor D, Goeckeritz J, Hasanpour Z, Davidson C, Lucke-Wold B. Nutritional Support Following Traumatic Brain Injury: A Comprehensive Review. EXPLORATORY RESEARCH AND HYPOTHESIS IN MEDICINE 2023; 8:236-247. [PMID: 37795213 PMCID: PMC10550050 DOI: 10.14218/erhm.2022.00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Traumatic brain injury (TBI) can contribute to extensive dysbiosis of the gastrointestinal system, leading to worsened outcomes. The importance of nutrition in recovery is underappreciated but highly important. In this focused review, we discuss the timing of nutritional interventions with supporting data. We highlight routes of administration that are important given the extent of injury often seen in TBI. The increased energy demands can be met through these approaches. Furthermore, patients need increased vitamins, minerals, and supplements. These interventions are constantly being refined. The current standards are reviewed with an emphasis on evidence-based practices.
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Affiliation(s)
- Divine Nwafor
- Department of Neurosurgery, West Virginia University, Morgantown, USA
| | - Joel Goeckeritz
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Zahra Hasanpour
- Department of Neurosurgery, University of Florida, Gainesville, USA
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24
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Xi F, You Y, Ding W, Gao T, Cao Y, Tan S, Yu W. Association of longitudinal changes in skeletal muscle mass with prognosis and nutritional intake in acutely hospitalized patients with abdominal trauma: a retrospective observational study. Front Nutr 2023; 10:1085124. [PMID: 37324740 PMCID: PMC10264603 DOI: 10.3389/fnut.2023.1085124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Background The objective of this study was to explore whether longitudinal changes in skeletal muscle mass, from hospital admission to 3 weeks post-trauma, are associated with poor prognosis and nutritional intake in acutely hospitalized patients with abdominal trauma. Methods A single-center retrospective observational review was conducted on 103 patients with abdominal trauma admitted to the Affiliated Jinling Hospital, Medical School of Nanjing University between January 2010 and April 2020. Skeletal muscle mass was assessed by abdominal computed tomography (CT) performed within 14 days before surgery and on post-trauma days 1-3 (week 0), 7-10 (week 1), 14-17 (week 2), and 21-24 (week 3). The skeletal muscle index (SMI) at L3, change in SMI per day (ΔSMI/day), and percent change in SMI per day (ΔSMI/day [%]) were calculated. The receiver-operating characteristic (ROC) curve was used to evaluate the discriminatory performance of ΔSMI/day (%) for mortality. Linear correlation analysis was used to evaluate the associations between ΔSMI/day (%) and daily caloric or protein intake. Results Among the included patients, there were 91 males and 12 females (mean age ± standard deviation 43.74 ± 15.53 years). ΔSMI4-1/d (%) had a ROC-area under the curve of 0.747 (p = 0.048) and a cut-off value of -0.032 for overall mortality. There were significant positive correlations between ΔSMI4-1/d (%) and daily caloric intake and protein intake (Y = 0.0007501*X - 1.397, R2 = 0.282, R = 0.531, p < 0.001; Y = 0.008183*X - 0.9228, R2 = 0.194, R = 0.440, p < 0.001). Δ SMI/day (%) was positively correlated with daily caloric intake ≥80% of resting energy expenditure in weeks 2, 3, and 1-3 post-trauma and with protein intake >1.2 g/kg/d in weeks 3 and 1-3 post-trauma. Conclusion Loss of skeletal muscle mass is associated with poor prognosis and nutritional intake in patients admitted to hospital with abdominal trauma.
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Affiliation(s)
- Fengchan Xi
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
- Department of Intensive Care Unit, Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, Jiangsu, China
| | - Yong You
- Department of Intensive Care Unit, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Weiwei Ding
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Tao Gao
- Department of Intensive Care Unit, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yang Cao
- Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shanjun Tan
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenkui Yu
- Department of Intensive Care Unit, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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25
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Rau CS, Tsai CH, Chou SE, Su WT, Hsu SY, Hsieh CH. The Addition of the Geriatric Nutritional Risk Index to the Prognostic Scoring Systems Did Not Improve Mortality Prediction in Trauma Patients in the Intensive Care Unit. Emerg Med Int 2023; 2023:3768646. [PMID: 37293272 PMCID: PMC10247323 DOI: 10.1155/2023/3768646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/20/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
Background Malnutrition is prevalent among critically ill patients and has been associated with a poor prognosis. This study sought to determine whether the addition of a nutritional indicator to the various variables of prognostic scoring models can improve the prediction of mortality among trauma patients in the intensive care unit (ICU). Methods This study's cohort included 1,126 trauma patients hospitalized in the ICU between January 1, 2018, and December 31, 2021. Two nutritional indicators, the prognostic nutrition index (PNI), a calculation based on the serum albumin concentration and peripheral blood lymphocyte count, and the geriatric nutritional risk index (GNRI), a calculation based on the serum albumin concentration and the ratio of current body weight to ideal body weight, were examined for their association with the mortality outcome. The significant nutritional indicator was served as an additional variable in prognostic scoring models of the Trauma and Injury Severity Score (TRISS), the Acute Physiology and Chronic Health Evaluation (APACHE II), and the mortality prediction models (MPM II) at admission, 24, 48, and 72 h in the mortality outcome prediction. The predictive performance was determined by the area under the receiver operating characteristic curve. Results Multivariate logistic regression revealed that GNRI (OR, 0.97; 95% CI, 0.96-0.99; p=0.007), but not PNI (OR, 0.99; 95% CI, 0.97-1.02; p=0.518), was independent risk factor for mortality. However, none of these predictive scoring models showed a significant improvement in prediction when the GNRI variable is incorporated. Conclusions The addition of GNRI as a variable to the prognostic scoring models did not significantly enhance the performance of the predictors.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Tsai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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26
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Wang S, Zhao X, Wang Q, Wu Y, Xu J, Li R, Zhou T, Lv Z, Yang J, Yang L, Zou X. Impact of early enteral nutrition on ventilator associated pneumonia in intubated severe trauma patients: A propensity score-matched study. Front Nutr 2023; 10:1172526. [PMID: 37125037 PMCID: PMC10130510 DOI: 10.3389/fnut.2023.1172526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/28/2023] [Indexed: 05/02/2023] Open
Abstract
Background Early enteral nutrition (EN) is recommended for critically ill patients. However, the impact of early EN on intubated severe trauma patients remains unclear. Methods Severely traumatized adult patients who received invasive mechanical ventilation (MV) for more than 48 h during intensive care unit (ICU) stay at our institution between 2017 and 2022 were retrospectively included. Early EN was defined as EN initiation ≤48 h from ICU admission and late EN >48 h. Propensity score matching (PSM) analysis was used to compare outcomes between the groups. The primary endpoint was the incidence of ventilator-associated pneumonia (VAP). Multivariable logistic regression analysis was performed to identify independent predictors of delayed EN. Results For final analysis, 337 intubated severe trauma patients were available, including 204 (60.5%) in the early EN group and 133 (39.5%) in the late EN group. After PSM, early EN patients had a lower incidence of VAP (12.9 vs. 25.8%, p = 0.026) and a shorter length of hospital stay (21 vs. 24 days, p = 0.015) compared to late EN patients. There was no demonstrable difference in mortality between the two groups. Abdominal trauma, massive blood transfusion, and serum albumin were identified as independent risk factors for delayed EN. Conclusion Early EN decreased the VAP rate and reduced the length of hospital stay in invasively ventilated patients with severe trauma. Abdominal injury, massive blood transfusion and low albumin were associated with delayed EN.
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Affiliation(s)
- Su Wang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Zhao
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Wang
- Department of Intensive Care Unit, Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaxin Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Zhou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng Lv
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jihong Yang
- Department of Critical Care Medicine, People’s Hospital of Chongyang County, Xianning, China
| | - Le Yang
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Le Yang,
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xiaojing Zou,
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27
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Ma Z, Zhang Y, Zhang Q, Wu B. Modified Nutrition Risk in Critically ill is an effective nutrition risk screening tool in severely burned patients, compared with Nutrition Risk Screening 2002. Front Nutr 2022; 9:1007885. [PMID: 36570140 PMCID: PMC9773874 DOI: 10.3389/fnut.2022.1007885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The present study aimed to evaluate the value of Modified Nutrition Risk in Critically ill (mNUTRIC) and Nutrition Risk Screening 2002 (NRS2002) in the prognosis of severely burned patients. Methods The retrospective cohort study used medical data of severely burned patients admitted to the burn center of Shanghai Ruijin Hospital between January 2015 and September 2021. Demographics, clinical characteristics, laboratory nutritional indicators, mNUTRIC score and NRS2002 score were collected and analyzed in evaluation the value of two nutrition risk screening tools. Spearman correlation analysis was carried out to show the correlation between variables. The area under receiver operating characteristic (ROC) curve was used to assess the ability of mNUTRIC and NRS2002 to predict mortality. Kaplan-Meier survival curves and log-rank tests were conducted to compare the overall survival (OS). Multivariate Cox proportional hazard regression model was used to identify risk factors for 28-day mortality of severely burned patients. Results A total of 429 adult patients with burn area larger than 30% total body surface area (TBSA) were included in this study. Incidence of nutrition risk was detected in 52.21% by mNUTRIC and 20.51% by NRS2002. However, mNUTRIC was superior to NRS2002 in predicting 28-day mortality (area under ROC curve: 0.795 vs. 0.726). Multivariate Cox regression analysis showed that high mNUTRIC [hazard ratio (HR) = 4.265, 95% CI = 1.469-12.380, P = 0.008] and TBSA (HR = 1.056, 95% CI = 1.033-1.079, P < 0.001) were independent predictors for 28-day mortality. After adjusting for covariates, high NRS2002 was not associated with 28-day mortality (P = 0.367). Conclusion The present study illustrated the effectiveness of mNUTRIC as nutrition risk screening tool among severely burned patients. Early identification of nutrition risk may help to maximize benefits of nutritional therapy by providing more aggressive nutritional therapy for patients at nutrition risk.
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Affiliation(s)
- Zhenzhu Ma
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yin Zhang
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Zhang
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,*Correspondence: Qin Zhang,
| | - Beiwen Wu
- Department of Nursing, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Beiwen Wu,
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28
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Fan Y, Yao Q, Liu Y, Jia T, Zhang J, Jiang E. Underlying Causes and Co-existence of Malnutrition and Infections: An Exceedingly Common Death Risk in Cancer. Front Nutr 2022; 9:814095. [PMID: 35284454 PMCID: PMC8906403 DOI: 10.3389/fnut.2022.814095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/24/2022] [Indexed: 12/16/2022] Open
Abstract
In nutrition science, malnutrition is a state of imbalance between intake and the needs of the organism, leading to metabolic changes, impaired physiological functions, and weight loss. Regardless of the countless efforts being taken and researched for years, the burden of malnutrition is still alarming and considered a significant agent of mortality across the globe. Around 45% of 12 million children deaths (0–5 years old) annually are due to malnutrition, mostly from developing countries. Malnutrition develops associations with other infections and leads to substantial clinical outcomes, such as mortality, more visits to hospitals, poor quality of life and physical frailty, and socioeconomic issues. Here, in this review, we intend to provide an overview of the current burden, underlying risk factors, and co-existence of malnutrition and other infections, such as cancer. Following the rising concern of the vicious interplay of malnutrition and other medical illnesses, we believed that this narrative review would highlight the need to re-make and re-define the future strategies by giving comprehensive and sustainable programs to alleviate poverty and combat the rampant infectious diseases and those nutrition-related health problems. Furthermore, the study also raises the concern for hospitalized malnourished cancer patients as it is crucially important to knowledge the caregiver healthcare staff for early interventions of providing nutritional support to delay or prevent the onset of malnutrition.
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Affiliation(s)
- Yuanyuan Fan
- School of Life Sciences, Henan University, Kaifeng, China
| | - Qianqian Yao
- Institute of Nursing and Health, Henan University, Kaifeng, China
| | - Yufeng Liu
- Institute of Nursing and Health, Henan University, Kaifeng, China
| | - Tiantian Jia
- Institute of Nursing and Health, Henan University, Kaifeng, China
- DeDepartment of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, China
| | - Junjuan Zhang
- DeDepartment of Orthopedics, Henan Provincial People's Hospital, Zhengzhou, China
- Junjuan Zhang
| | - Enshe Jiang
- Institute of Nursing and Health, Henan University, Kaifeng, China
- Henan International Joint Laboratory for Nuclear Protein Regulation, Henan University, Kaifeng, China
- *Correspondence: Enshe Jiang
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29
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Guenter P, Blackmer A, Malone A, Mirtallo JM, Phillips W, Tyler R, Barrocas A, Resnick HE, Anthony P, Abdelhadi R. Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States. Nutr Clin Pract 2022; 37:94-101. [PMID: 35025121 DOI: 10.1002/ncp.10827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Malnutrition continues to be associated with outcomes in hospitalized patients. METHODS An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data. RESULTS Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN. CONCLUSION Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.
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Affiliation(s)
- Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Allison Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Jay M Mirtallo
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | | | - Renay Tyler
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | | | - Pat Anthony
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ruba Abdelhadi
- University of Kansas School of Medicine, Kansas City, MO, USA
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Hartwell JL, Peck KA, Ley EJ, Brown CVR, Moore EE, Sperry JL, Rizzo AG, Rosen NG, Brasel KJ, Weinberg JA, de Moya MA, Inaba K, Cotton A, Martin MJ. Nutrition therapy in the critically injured adult patient: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 91:909-915. [PMID: 34162798 DOI: 10.1097/ta.0000000000003326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer L Hartwell
- From the Indiana University Department of Surgery (J.L.H.), Indianapolis, Indiana; Department of Surgery (K.A.P., M.J.M.), Scripps Mercy Hospital, San Diego, California; Division of Trauma and Acute Care Surgery, Department of Surgery (E.J.L.), Cedars-Sinai Medical Center, Los Angeles, California; Department of Surgery (C.V.R.B.), Dell Medical School, University of Texas at Austin, Austin, Texas; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado; Department of Surgery (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania; Inova Fairfax Trauma Services (A.G.R.), Falls Church, Virginia; Division of Pediatric General and Thoracic Surgery (N.G.R.), Cincinnati Children's Hospital, Cincinnati, Ohio; Division of Trauma/Critical Care, Department of Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Creighton University School of Medicine Phoenix Regional Campus, St. Joseph's Hospital and Medical Center (J.A.W.), Phoenix, Arizona; Division of Trauma/Acute Care Surgery, Department of Sugery (M.A.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Trauma and Surgical Critical Care, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Clinical Dietetics (A.C.), IU Health Methodist Hospital, Indianapolis, Indiana
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Correia MITD, Sulo S, Brunton C, Sulz I, Rodriguez D, Gomez G, Tarantino S, Hiesmayr M. Prevalence of malnutrition risk and its association with mortality: nutritionDay Latin America survey results. Clin Nutr 2021; 40:5114-5121. [PMID: 34461585 DOI: 10.1016/j.clnu.2021.07.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/08/2021] [Accepted: 07/16/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Across the globe, the prevalence of hospital malnutrition varies greatly depending on the population served and on local socioeconomic conditions. While malnutrition is widely recognized to worsen patient outcomes and add financial burdens to healthcare systems, recent data on hospital malnutrition in Latin America are limited. Our study objectives were: (1) to quantify the prevalence of malnutrition risk in Latin American hospital wards, and (2) to explore associations between nutritional risk status, in-hospital food intake, and health outcomes. METHODS On nutritionDay (nDay), a specific day every year, hospital wards worldwide can participate in a one-day, cross-sectional audit. We analyzed nDay data collected in ten Latin American countries from 2009 to 2015, including demographic and nutrition-related findings for adult patients (≥18 years) from 582 hospital wards/units. Based on patient-reported responses to questions related to the Malnutrition Screening Tool, we determined the prevalence of malnutrition risk (MST score ≥2). We also summarized patient-reported food intake on nDay, and we analyzed staff-collected outcome data at 30 days post-nDay. RESULTS The prevalence of malnutrition risk in the Latin American nDay study population (N = 14,515) was 39.6%. More than 50% of studied patients ate one-half or less of their hospital meal, ate less than normal in the week before nDay, or experienced weight loss in the prior three months. The hospital-mortality hazard ratio was 3.63 (95% CI [2.71, 4.88]; P < 0.001) for patients eating one-quarter of their meal (compared with those who ate the full meal), increasing to 6.6 (95% CI [5.02, 8.7]; P < 0.0001) for patients who ate none of the food offered. CONCLUSIONS Based on compilation of nDay surveys throughout Latin America, 2 of every 5 hospitalized patients were at risk for malnutrition. The associated risk for hospital mortality was up to 6-fold higher among patients who ate little or none of their meal on nDay. This high prevalence showed scant improvement over rates two decades ago-a compelling rationale for new focus on nutrition education and training of professionals in acute care settings.
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Affiliation(s)
- M Isabel T D Correia
- Department of Surgery, Universidade Federal de Minas Gerais Medical School, Belo Horizonte, Brazil
| | | | | | - Isabella Sulz
- Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems Medical University Vienna, Vienna, Austria
| | - Dolores Rodriguez
- Clinical Nutrition Department, SOLCA Cancer Hospital, Guayaquil, Ecuador
| | | | - Silvia Tarantino
- Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems Medical University Vienna, Vienna, Austria
| | - Michael Hiesmayr
- Institute for Medical Statistics, Center for Medical Statistics, Informatics and Intelligent Systems Medical University Vienna, Vienna, Austria
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Hsieh CH, Liu YW, Tsai CH, Chou SE, Su WT, Li C, Hsu SY. Geriatric nutritional risk index in screening malnutrition among young adult and elderly trauma patients. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_44_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Upadhyaya GK, Iyengar KP, Jain VK, Garg R. Evolving concepts and strategies in the management of polytrauma patients. J Clin Orthop Trauma 2021; 12:58-65. [PMID: 33716429 PMCID: PMC7920163 DOI: 10.1016/j.jcot.2020.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.
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Affiliation(s)
- Gaurav K. Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
- Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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Yeh CH, Wu SC, Chou SE, Su WT, Tsai CH, Li C, Hsu SY, Hsieh CH. Geriatric Nutritional Risk Index as a Tool to Evaluate Impact of Malnutrition Risk on Mortality in Adult Patients with Polytrauma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249233. [PMID: 33321867 PMCID: PMC7764093 DOI: 10.3390/ijerph17249233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Identification of malnutrition is especially important in severely injured patients, in whom hypermetabolism and protein catabolism following traumatic injury worsen their nutritional condition. The geriatric nutritional risk index (GNRI), based on serum albumin level and the current body weight/ideal body weight ratio, is useful for identifying patients with malnutrition in many clinical conditions. This study aimed to explore the association between admission GNRI and mortality outcomes of adult patients with polytrauma. METHODS From 1 January 2009 to 31 December 2019, a total of 348 adult patients with polytrauma, registered in the trauma database of a level I trauma center, were recognized and categorized into groups of death (n = 71) or survival (n = 277) and into four nutritional risk groups: a high-risk group (GNRI < 82, n = 87), a moderate-risk group (GNRI 82 to <92, n = 144), a low-risk group (GNRI 92-98, n = 59), and a no-risk group (GNRI > 98, n = 58). Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for mortality. The mortality outcomes of patients at various nutritional risks were compared to those of patients in the no-risk group. RESULTS The comparison between the death group (n = 71) and the survival group (n = 277) revealed that there was no significant difference in gender predominance, age, pre-existing comorbidities, injury mechanism, systolic blood pressure, and respiratory rate upon arrival at the emergency room. A significantly lower GNRI and Glasgow Coma Scale score but higher injury severity score (ISS) was observed in the death group than in the survival group. Multivariate logistic regression analysis revealed that Glasgow Coma Scale (GCS), odds ratio (OR), 0.88; 95% confidence interval (CI), 0.83-0.95; p < 0.001), ISS (OR, 1.07; 95% CI, 1.04-1.11; p < 0.001), and GNRI (OR, 0.94; 95% CI, 0.91-0.97; p < 0.001) were significant independent risk factors for mortality in these patients. The mortality rates for the high-risk, moderate-risk, low-risk, and no-risk groups were 34.5%, 20.1%, 8.5%, and 12.1%, respectively. Unlike patients in the moderate-risk and low-risk groups, patients in the high-risk group had a significantly higher death rate than that of those in the no-risk group. CONCLUSIONS This study revealed that the GNRI may serve as a simple, promising screening tool to identify the high risk of malnutrition for mortality in adult patients with polytrauma.
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Affiliation(s)
- Cheng-Hsi Yeh
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan;
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan; (S.-E.C.); (W.-T.S.); (C.-H.T.); (C.L.); (S.-Y.H.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan; (S.-E.C.); (W.-T.S.); (C.-H.T.); (C.L.); (S.-Y.H.)
| | - Ching-Hua Tsai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan; (S.-E.C.); (W.-T.S.); (C.-H.T.); (C.L.); (S.-Y.H.)
| | - Chi Li
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan; (S.-E.C.); (W.-T.S.); (C.-H.T.); (C.L.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan; (S.-E.C.); (W.-T.S.); (C.-H.T.); (C.L.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung City 83301, Taiwan
- Correspondence: ; Tel.: +886-7-7327476
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