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Watanabe S, Izumino H, Takatani Y, Tsutsumi R, Suzuki T, Tatsumi H, Yamamoto R, Sato T, Miyagi T, Miyajima I, Nakamura K, Higashibeppu N, Kotani J. Effects of Energy Delivery Guided by Indirect Calorimetry in Critically Ill Patients: A Systematic Review and Meta-Analysis. Nutrients 2024; 16:1452. [PMID: 38794690 PMCID: PMC11124016 DOI: 10.3390/nu16101452] [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: 04/07/2024] [Revised: 05/03/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The utility of using indirect calorimetry (IC) to estimate energy needs and methods for its application to this purpose remain unclear. This systematic review investigated whether using IC to estimate energy expenditure in critically ill patients is more meaningful for improving survival than other estimation methods. METHODS Comprehensive searches were conducted in MEDLINE using PubMed, Cochrane Central Register of Controlled Trials, and Igaku-Chuo-Zasshi up to March 2023. RESULTS Nine RCTs involving 1178 patients were included in the meta-analysis. The evidence obtained suggested that energy delivery by IC improved short-term mortality (risk ratio, 0.86; 95% confidence interval [CI], 0.70 to 1.06). However, the use of IC did not appear to affect the length of ICU stay (mean difference [MD], 0.86; 95% CI, -0.98 to 2.70) or the duration of mechanical ventilation (MD, 0.66; 95% CI, -0.39 to 1.72). Post hoc analyses using short-term mortality as the outcome found no significant difference by target calories in resting energy expenditure, whereas more frequent IC estimates were associated with lower short-term mortality and were more effective in mechanically ventilated patients. CONCLUSIONS This updated meta-analysis revealed that the use of IC may improve short-term mortality in patients with critical illness and did not increase adverse events.
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Affiliation(s)
- Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, 2-92 Higashiuzura, Gifu 500-8281, Japan;
| | - Hiroo Izumino
- Acute and Critical Care Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan;
| | - Yudai Takatani
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan;
| | - Rie Tsutsumi
- Department of Nutrition and Metabolism, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto, Tokushima 770-8503, Japan;
| | - Takahiro Suzuki
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan;
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, S1 W17, Chuo-ku, Sapporo 060-8556, Japan;
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan;
| | - Takeaki Sato
- Emergency Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan;
| | - Tomoka Miyagi
- Department of Nutrition, Yokosuka General Hospital, 2-36 Uwamachi, Yokosuka 238-8567, Japan;
| | - Isao Miyajima
- Department of Clinical Nutrition, Chikamori Hospital, 1-1-16 Okawasuzi, Kochi 780-8522, Japan;
| | - Kensuke Nakamura
- Department of Intensive Care, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0064, Japan;
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe 650-0047, Japan;
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
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Cheng L, Zhang F, Xue W, Yu P, Wang X, Wang H, Wang J, Hu T, Gong H, Lin L. Association of dynamic change of triglyceride-glucose index during hospital stay with all-cause mortality in critically ill patients: a retrospective cohort study from MIMIC IV2.0. Cardiovasc Diabetol 2023; 22:142. [PMID: 37330498 PMCID: PMC10276426 DOI: 10.1186/s12933-023-01874-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/02/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Biomarker of insulin resistance, namely triglyceride-glucose index, is potentially useful in identifying critically ill patients at high risk of hospital death. However, the TyG index might have variations over time during ICU stay. Hence, the purpose of the current research was to verify the associations between the dynamic change of the TyG index during the hospital stay and all-cause mortality. METHODS The present retrospective cohort study was conducted using the Medical Information Mart for Intensive Care IV 2.0 (MIMIC-IV) critical care dataset, which included data from 8835 patients with 13,674 TyG measurements. The primary endpoint was 1-year all-cause mortality. Secondary outcomes included in-hospital all-cause mortality, the need for mechanical ventilation during hospitalization, length of stay in the hospital. Cumulative curves were calculated using the Kaplan-Meier method. Propensity score matching was performed to reduce any potential baseline bias. Restricted cubic spline analysis was also employed to assess any potential non-linear associations. Cox proportional hazards analyses were performed to examine the association between the dynamic change of TyG index and mortality. RESULTS The follow-up period identified a total of 3010 all-cause deaths (35.87%), of which 2477 (29.52%) occurred within the first year. The cumulative incidence of all-cause death increased with a higher quartile of the TyGVR, while there were no differences in the TyG index. Restricted cubic spline analysis revealed a nearly linear association between TyGVR and the risk of in-hospital all-cause mortality (P for non-linear = 0.449, P for overall = 0.004) as well as 1-year all-cause mortality (P for non-linear = 0.909, P for overall = 0.019). The area under the curve of all-cause mortality by various conventional severity of illness scores significantly improved with the addition of the TyG index and TyGVR. The results were basically consistent in subgroup analysis. CONCLUSIONS Dynamic change of TyG during hospital stay is associated with in-hospital and 1-year all-cause mortality, and may be superior to the effect of baseline TyG index.
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Affiliation(s)
- Long Cheng
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Wenjing Xue
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Peng Yu
- Department of Urology, Shanghai Punan Hospital of Pudong New District, Punan Branch of Renji Hospital, No. 279 Linyi Road, Shanghai, 200000, China
| | - Xiaoyan Wang
- Institute of Cardiovascular Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Hairong Wang
- Department of Cardiovascular Medicine, Shanghai Pudong New Area Gongli Hospital, Shanghai, 200000, People's Republic of China
| | - Jun Wang
- Department of Neurology, First People's Hospital of Yancheng, Yulong Western Road, Yancheng, 224006, Jiangsu, China
| | - Tianyang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hui Gong
- Department of Cardiology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Li Lin
- Department of Cardiovascular Medicine,, Shanghai East Hospital, Tongji University School of Medicine, Jimo Road 150, Shanghai, 200120, China.
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Formenti P, Coppola S, Umbrello M, Froio S, Caccioppola A, De Giorgis V, Galanti V, Lusardi AC, Ferrari E, Noè D, Carnier S, Folli F, Chiumello D. Time course of the Bioelectrical Impedance Vector Analysis and muscular ultrasound in critically ill patients. J Crit Care 2021; 68:89-95. [PMID: 34952476 DOI: 10.1016/j.jcrc.2021.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Several different tools have been developed to integrate the clinical and biochemical nutritional evaluations in critical care patients. Aims of this study were to evaluate the changes in the Bioelectrical Impedance Vector Analysis (BIVA) and ultrasonographic features of the diaphragm (DTee) and rectus femoris (RFCSA) during the first week of ICU stay. MATERIALS AND METHODS Ninety-six adult mechanically ventilated patients enrolled within 24 h after the admission to the ICU (T1). RFCSA and diaphragm end-expiratory thickness were measured, as well as BIVA parameters. Anthropometric data and biochemical parameters were collected. The measurements were repeated on the 3rd (T3) and 7th (T7) days of ICU stay. RESULTS During the study period, the phase angle significantly decreased by 21%, reactance by 27%, and resistance by 11%. Both RFCSA and DTee significantly decreased, while neither were correlated to any BIVA parameter. DTee was considerably higher in survivors vs. non-survivors. CONCLUSIONS Body composition is significantly modified after one week of ICU stay. BIVA may be useful in the definition of hydration state, while it does not seem to track muscle mass. Different temporal trends of specific BIVA and muscle ultrasound parameters were found in patients with high or low severity of illness.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sara Froio
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Alessio Caccioppola
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Valentina De Giorgis
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Valentina Galanti
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Andrea Clarissa Lusardi
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Erica Ferrari
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Donatella Noè
- SSD Servizio Dietetico e Nutrizione Clinica- ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy
| | - Simone Carnier
- Endocrinology and Metabolism, Department of Health Science, University of Milan - ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy
| | - Franco Folli
- Endocrinology and Metabolism, Department of Health Science, University of Milan - ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy; Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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Body Composition Findings by Computed Tomography in SARS-CoV-2 Patients: Increased Risk of Muscle Wasting in Obesity. Int J Mol Sci 2020; 21:ijms21134670. [PMID: 32630032 PMCID: PMC7370146 DOI: 10.3390/ijms21134670] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 12/16/2022] Open
Abstract
Obesity is a characteristic of COVID-19 patients and the risk of malnutrition can be underestimated due to excess of fat: a paradoxical danger. Long ICU hospitalization exposes patients to a high risk of wasting and loss of lean body mass. The complex management precludes the detection of anthropometric parameters for the definition and monitoring of the nutritional status. The use of imaging diagnostics for body composition could help to recognize and treat patients at increased risk of wasting with targeted pathways. COVID-19 patients admitted to the ICU underwent computed tomography within 24 h and about 20 days later, to evaluate the parameters of the body and liver composition. The main results were the loss of the lean mass index and a greater increase in liver attenuation in obese subjects. These could be co-caused by COVID-19, prolonged bed rest, the complex medical nutritional therapy, and the starting condition of low-grade inflammation of the obese. The assessment of nutritional status, with body composition applied to imaging diagnostics and metabolic profiles in COVID-19, will assist in prescribing appropriate medical nutritional therapy. This will reduce recovery times and complications caused by frailty.
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Chen W, Wang H, Chen Y, Yuan D, Chen R. The independent risk factors of early diarrhoea in enteral nutrition for ICU patients. J Int Med Res 2019; 47:4929-4939. [PMID: 31507229 PMCID: PMC6833384 DOI: 10.1177/0300060519868340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To investigate the prevalence of and factors associated with diarrhoea in the early stage of enteral nutrition in critically ill patients in intensive care units (ICUs). Methods This prospective, multicentre, observational study enrolled consecutive patients who were newly admitted to ICUs and received enteral nutrition treatment. Events were observed continuously for 7 days or until patients were transferred out of the ICU after enteral nutrition. Demographic and clinical data, enteral nutrition data, diarrhoea-related data and outcomes were recorded. A multivariate logistic regression analysis was used to analyse the risk factors for diarrhoea. Results The study included 533 patients, of whom 164 (30.8%) developed diarrhoea. Diarrhoea was most commonly observed on the first to third days after starting enteral nutrition treatment. The median (interquartile range) duration of diarrhoea was 2 (1–3) days. The administration of gastrointestinal prokinetic agents, the increase in acute physiological and chronic health scores and the pyloric posterior feeding method were independent risk factors for diarrhoea. Conclusion The increased severity of illness, the administration of gastrointestinal prokinetic agents and the pyloric posterior feeding method were independent risk factors for diarrhoea in critically ill ICU patients undergoing enteral nutrition treatment.
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Affiliation(s)
- Weiting Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Hehao Wang
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Yingzi Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Danqin Yuan
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Renhui Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
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Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
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Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
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Malekolkottab M, Khalili H, Mohammadi M, Ramezani M, Nourian A. Metoclopramide as intermittent and continuous infusions in critically ill patients: a pilot randomized clinical trial. J Comp Eff Res 2017; 6:127-136. [PMID: 28114798 DOI: 10.2217/cer-2016-0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIM Metoclopramide is commonly used as a prokinetic agent in critically ill patients with enteral feeding intolerance. In this study, noninferiority of metoclopramide as intermittent versus continuous infusion was examined in critically ill patients with enteral feeding intolerance. METHODS Forty critically ill adults patients were assigned to receive metoclopramide as either intermittent (10 mg every 6 h) or continuous (2 mg/h) infusion. Frequency of feeding intolerance and adverse effects of metoclopramide were assessed during 7 days of study. RESULTS Number of patients with feeding intolerance during different times of the course was not different between the groups. Although not statistically significant, diarrhea and cardiac rhythm were more common in continuous than intermittent infusion group. CONCLUSION Continuous and intermittent infusions of metoclopramide showed equivalent effectiveness in critically ill patients.
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Affiliation(s)
- Masoume Malekolkottab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Ramezani
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahid Nourian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Patel JJ, Kha V, Butler D, Kozeniecki M, Martindale R, Allen K. Organ-Specific Nutrition: One for the History Books or Still an Active Player? CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0149-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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9
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Marshall AP, Wake E, Weisbrodt L, Dhaliwal R, Spencer A, Heyland DK. A multi-faceted, family-centred nutrition intervention to optimise nutrition intake of critically ill patients: The OPTICS feasibility study. Aust Crit Care 2015; 29:68-76. [PMID: 26603213 DOI: 10.1016/j.aucc.2015.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Critically ill patients are at risk of developing malnutrition which contributes to functional decline and hospital re-admission. Strategies to promote nutritional intake have had a modest effect on protein-calorie intake. None have addressed the recovery trajectory of critical illness or incorporated family as advocates. OBJECTIVES We evaluated the feasibility and acceptability of a family-centred intervention designed to optimise nutrition during and following recovery from critical illness. DESIGN A prospective cohort study. SETTING Two Australian adult intensive care units. PARTICIPANTS A convenience sample of 49 patients and their families was recruited. Patients ≥18 years of age anticipated to require mechanical ventilation for at least 2 days were eligible, provided their family visited regularly and were able to communicate in English. Health care professionals including doctors (n=4), nurses (n=20) and dietitians (n=2) also participated. METHODS Demographic data were obtained from participants. Recruitment and retention informed study feasibility. Individual and group interviews informed participant views on the acceptability, perception of and experience with the intervention. Inductive analysis was used to analyse qualitative data. RESULTS 187 (15.8%) patients met the eligibility criteria; 49 patients and 51 family members consented to participate for a 20.3% consent failure rate. We interviewed 33 (67.3%) family members and 13 (43.4%) patients, all of whom considered the intervention acceptable and who would participate in a similar intervention again, given the opportunity. Inductive analysis of qualitative data from all participants identified three themes: variability in in-hospital nutrition support, families as advocates for optimal nutrition, and partnering with health care providers. CONCLUSION We described a feasible and acceptable family centred intervention that may be effective in promoting nutrition intake in critically ill patients. Further research is required to examine contextual factors impacting implementation of family-centred interventions, particularly those that involve active family participation and advocacy.
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Affiliation(s)
- Andrea P Marshall
- NHMRC Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University and Gold Coast Health, Australia; Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Elizabeth Wake
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | | | | | - Alan Spencer
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, 76 Stuart Street, Suite 5-416, Kingston, Ontario, Canada K7L 2V7; Queen's University, 99 University Avenue, Kingston, Ontario, Canada K7L 3N6.
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Preiser JC, Ichai C, Orban JC, Groeneveld A. Metabolic response to the stress of critical illness. Br J Anaesth 2014; 113:945-54. [DOI: 10.1093/bja/aeu187] [Citation(s) in RCA: 221] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Ren T, Cong L, Wang Y, Tang Y, Tian B, Lin X, Zhang Y, Tang X. Lipid emulsions in parenteral nutrition: current applications and future developments. Expert Opin Drug Deliv 2013; 10:1533-49. [PMID: 23919912 DOI: 10.1517/17425247.2013.824874] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION A parenteral lipid emulsion (LE), used as a key source of energy, essential fatty acids (FAs), and fat-soluble vitamins, is an integral part of a parenteral nutrition (PN) regimen. The conventional LEs, such as soybean oil (SO)-based emulsions, have caused concerns about the potential adverse effects involving oxidative stress, inflammation, and immune response probably because of undesirable FA composition. AREAS COVERED Recently, alternative LEs, optimizing the FA composition with partial substitution of SO with medium-chain triglyceride (MCT), olive oil (OO), and fish oil (FO), have been developed and applied in clinical practice. This review summarizes the characteristics and beneficial clinical effects of alternative parenteral LEs in critically ill, pediatric, and long-term PN patients. EXPERT OPINION More clinical data from sufficiently high-powered studies are required to characterize the integral biological properties of alternative LEs for further selection to fit individual needs and disease characteristics. Simultaneously, potential lipid sources with desirable FA compositions and biological properties should be selected to develop new therapeutic LEs. As supplements to current parenteral lipids, the new LEs with different therapeutic effects are expected to fit specified subpopulations of patients with different diseases. Great efforts should be devoted to the development of parenteral LEs.
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Affiliation(s)
- Tianyang Ren
- Shenyang Pharmaceutical University, Department of Pharmaceutics Science , Shenyang , China
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13
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Hoffer LJ, Bistrian BR. Appropriate protein provision in critical illness: a systematic and narrative review. Am J Clin Nutr 2012; 96:591-600. [PMID: 22811443 DOI: 10.3945/ajcn.111.032078] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Widely varying recommendations have been published with regard to the appropriate amount of protein or amino acids to provide in critical illness. OBJECTIVE We carried out a systematic review of clinical trials that compared the metabolic or clinical effects of different protein intakes in adult critical illness and comprehensively reviewed all of the available evidence pertinent to the safe upper limit of protein provision in this setting. DESIGN MEDLINE was searched for clinical trials published in English between 1948 and 2012 that provided original data comparing the effects of different levels of protein intake on clinically relevant outcomes and evidence pertinent to the safe upper limit of protein provision to critically ill adults. RESULTS The limited amount and poor quality of the evidence preclude conclusions or clinical recommendations but strongly suggest that 2.0-2.5 g protein substrate · kg normal body weight⁻¹ · d⁻¹ is safe and could be optimum for most critically ill patients. At the present time, most critically ill adults receive less than half of the most common current recommendation, 1.5 g protein · kg⁻¹ · d⁻¹, for the first week or longer of their stay in an intensive care unit. CONCLUSION There is an urgent need for well-designed clinical trials to identify the appropriate level of protein provision in critical illness.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.
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14
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Mesejo A, Sánchez Álvarez C, Arboleda Sánchez JA. [Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): obese patient]. Med Intensiva 2012; 35 Suppl 1:57-62. [PMID: 22309755 DOI: 10.1016/s0210-5691(11)70012-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As a response to metabolic stress, obese critically-ill patients have the same risk of nutritional deficiency as the non-obese and can develop protein-energy malnutrition with accelerated loss of muscle mass. The primary aim of nutritional support in these patients should be to minimize loss of lean mass and accurately evaluate energy expenditure. However, routinely-used formulae can overestimate calorie requirements if the patient's actual weight is used. Consequently, the use of adjusted or ideal weight is recommended with these formulae, although indirect calorimetry is the method of choice. Controversy surrounds the question of whether a strict nutritional support criterion, adjusted to the patient's requirements, should be applied or whether a certain degree of hyponutrition should be allowed. Current evidence suggested that hypocaloric nutrition can improve results, partly due to a lower rate of infectious complications and better control of hyperglycemia. Therefore, hypocaloric and hyperproteic nutrition, whether enteral or parenteral, should be standard practice in the nutritional support of critically-ill obese patients when not contraindicated. Widely accepted recommendations consist of no more than 60-70% of requirements or administration of 11-14 kcal/kg current body weight/day or 22-25 kcal/kg ideal weight/day, with 2-2.5 g/kg ideal weight/day of proteins. In a broad sense, hypocaloric-hyperprotein regimens can be considered specific to obese critically-ill patients, although the complications related to comorbidities in these patients may require other therapeutic possibilities to be considered, with specific nutrients for hyperglycemia, acute respiratory distress syndrome (ARDS) and sepsis. However, there are no prospective randomized trials with this type of nutrition in this specific population subgroup and the available data are drawn from the general population of critically-ill patients. Consequently, caution should be exercised when interpreting these data.
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Affiliation(s)
- A Mesejo
- Hospital Clínico Universitario, Valencia, España.
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15
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Preiser JC. Do we need an assessment of the nutrition risk in the critically ill patient? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:101. [PMID: 22236982 PMCID: PMC3396220 DOI: 10.1186/cc10572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The description of a new score of nutrition risk in critically ill patients in the previous issue of Critical Care is very appropriate and timely. However, the use of this score will probably not help the clinician to improve the prescription of nutrition therapy, especially when major uncertainties are raised about the definition of adequate nutrition. The validation of the score will require the use of outcome variables susceptible to influence by nutrition, such as surrogate markers of muscle function. Meanwhile the educational value of a score of nutrition risk is undisputed in settings where the use of scores is incorporated into the usual practice.
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Affiliation(s)
- Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, 808 route de Lennik, 1070 Brussels, Belgium.
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16
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Xu Z, Li Y, Wang J, Wu B, Li J. Effect of omega-3 polyunsaturated fatty acids to reverse biopsy-proven parenteral nutrition-associated liver disease in adults. Clin Nutr 2011; 31:217-23. [PMID: 22035955 DOI: 10.1016/j.clnu.2011.10.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 09/27/2011] [Accepted: 10/01/2011] [Indexed: 01/22/2023]
Abstract
BACKGROUND & AIMS Parenteral nutrition-associated liver disease (PNALD) complicates the treatment of patients with short bowel syndrome (SBS). Some studies have shown omega-3 polyunsaturated fatty acids (ω-3 PUFAs) have favorable effects in treating PNALD in children. We, therefore, investigate the effects of ω-3 PUFAs supplemented intravenous lipid emulsion (ILE) on PNALD in adults. METHODS We performed an open-labeled study of a ω-3 PUFAs based ILE in 15 adults with SBS who developed cholestasis while receiving soybean oil-based ILE. Liver biopsies were performed before and after the initiation of ω-3 PUFAs to confirm the presence and improvement of cholestasis. Blood samples were collected every week for analysis of fatty acid composition and liver function. RESULTS 12 of the 15 patients had their direct bilirubin normalized within 4 weeks and our data demonstrated a significant decrease in both DB (P ≤ 0.001) and TB (P ≤ 0.001) after 4 weeks compared to baseline. There were ameliorations of liver function and fatty acid patterns in all patients and serial liver biopsy specimens showed progressive histologic improvement. CONCLUSIONS Parenteral ω-3 PUFAs supplemented fat emulsions are safe and effective in the treatment of PNALD in adults.
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Affiliation(s)
- Ziwei Xu
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 E Zhongshan Rd, Nanjing 210002, PR China
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17
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Gervasio JM, Garmon WP, Holowatyj M. Nutrition Support in Acute Kidney Injury. Nutr Clin Pract 2011; 26:374-81. [DOI: 10.1177/0884533611414029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Jane M. Gervasio
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Wesley P. Garmon
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
| | - Michael Holowatyj
- Butler University, College of Pharmacy and Health Science, Indianapolis, Indiana
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Elevation of blood urea nitrogen is predictive of long-term mortality in critically ill patients independent of "normal" creatinine. Crit Care Med 2011; 39:305-13. [PMID: 21099426 DOI: 10.1097/ccm.0b013e3181ffe22a] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We hypothesized that elevated blood urea nitrogen can be associated with all-cause mortality independent of creatinine in a heterogeneous critically ill population. DESIGN Multicenter observational study of patients treated in medical and surgical intensive care units. SETTING Twenty intensive care units in two teaching hospitals in Boston, MA. PATIENTS A total of 26,288 patients, age ≥ 18 yrs, hospitalized between 1997 and 2007 with creatinine of 0.80-1.30 mg/dL. INTERVENTIONS None. MEASUREMENTS Blood urea nitrogen at intensive care unit admission was categorized as 10-20, 20-40, and >40 mg/dL. Logistic regression examined death at days 30, 90, and 365 after intensive care unit admission as well as in-hospital mortality. Adjusted odds ratios were estimated by multivariable logistic regression models. MAIN RESULTS Blood urea nitrogen at intensive care unit admission was predictive for short- and long-term mortality independent of creatinine. Thirty days following intensive care unit admission, patients with blood urea nitrogen of >40 mg/dL had an odds ratio for mortality of 5.12 (95% confidence interval, 4.30-6.09; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Blood urea nitrogen remained a significant predictor of mortality at 30 days after intensive care unit admission following multivariable adjustment for confounders; patients with blood urea nitrogen of >40 mg/dL had an odds ratio for mortality of 2.78 (95% confidence interval, 2.27-3.39; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Thirty days following intensive care unit admission, patients with blood urea nitrogen of 20-40 mg/dL had an odds ratio of 2.15 (95% confidence interval, 1.98-2.33; <.0001) and a multivariable odds ratio of 1.53 (95% confidence interval, 1.40-1.68; p < .0001) relative to patients with blood urea nitrogen of 10-20 mg/dL. Results were similar at 90 and 365 days following intensive care unit admission as well as for in-hospital mortality. A subanalysis of patients with blood cultures (n = 7,482) demonstrated that blood urea nitrogen at intensive care unit admission was associated with the risk of blood culture positivity. CONCLUSION Among critically ill patients with creatinine of 0.8-1.3 mg/dL, an elevated blood urea nitrogen was associated with increased mortality, independent of serum creatinine.
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19
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Wiesen P, Van Overmeire L, Delanaye P, Dubois B, Preiser JC. Nutrition Disorders During Acute Renal Failure and Renal Replacement Therapy. JPEN J Parenter Enteral Nutr 2011; 35:217-22. [DOI: 10.1177/0148607110377205] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Patricia Wiesen
- Department of General Intensive Care, University Hospital Centre of Liege, Belgium
| | | | - Pierre Delanaye
- Department of Nephrology, University Hospital Centre of Liege, Belgium
| | - Bernard Dubois
- Department of Nephrology, University Hospital Centre of Liege, Belgium
| | - Jean-Charles Preiser
- Department of General Intensive Care, University Hospital Centre of Liege, Belgium
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20
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Ichai C, Preiser JC. International recommendations for glucose control in adult non diabetic critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R166. [PMID: 20840773 PMCID: PMC3219261 DOI: 10.1186/cc9258] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 07/22/2010] [Accepted: 09/14/2010] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The purpose of this research is to provide recommendations for the management of glycemic control in critically ill patients. METHODS Twenty-one experts issued recommendations related to one of the five pre-defined categories (glucose target, hypoglycemia, carbohydrate intake, monitoring of glycemia, algorithms and protocols), that were scored on a scale to obtain a strong or weak agreement. The GRADE (Grade of Recommendation, Assessment, Development and Evaluation) system was used, with a strong recommendation indicating a clear advantage for an intervention and a weak recommendation indicating that the balance between desirable and undesirable effects of an intervention is not clearly defined. RESULTS A glucose target of less than 10 mmol/L is strongly suggested, using intravenous insulin following a standard protocol, when spontaneous food intake is not possible. Definition of the severe hypoglycemia threshold of 2.2 mmol/L is recommended, regardless of the clinical signs. A general, unique amount of glucose (enteral/parenteral) to administer for any patient cannot be suggested. Glucose measurements should be performed on arterial rather than venous or capillary samples, using central lab or blood gas analysers rather than point-of-care glucose readers. CONCLUSIONS Thirty recommendations were obtained with a strong (21) and a weak (9) agreement. Among them, only 15 were graded with a high level of quality of evidence, underlying the necessity to continue clinical studies in order to improve the risk-to-benefit ratio of glucose control.
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Affiliation(s)
- Carole Ichai
- Medical and Surgical Intensive Care Unit, Saint-Roch Hospital, University of Medicine of Nice, 06000 Nice, France.
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21
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Soporte nutricional en la insuficiencia renal aguda. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70571-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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22
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Btaiche IF, Chan LN, Pleva M, Kraft MD. Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract 2010; 25:32-49. [PMID: 20130156 DOI: 10.1177/0884533609357565] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.
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Affiliation(s)
- Imad F Btaiche
- University of Michigan Hospitals and Health Centers, Pharmacy Services, UHB2D301, 1500 E. Med. Center Drive, Ann Arbor, MI 48109-0008, USA.
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23
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Suhaimi F, Le Compte A, Preiser JC, Shaw GM, Massion P, Radermecker R, Pretty CG, Lin J, Desaive T, Chase JG. What makes tight glycemic control tight? The impact of variability and nutrition in two clinical studies. J Diabetes Sci Technol 2010; 4:284-98. [PMID: 20307388 PMCID: PMC2864163 DOI: 10.1177/193229681000400208] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tight glycemic control (TGC) remains controversial while successful, consistent, and effective protocols remain elusive. This research analyzes data from two TGC trials for root causes of the differences achieved in control and thus potentially in glycemic and other outcomes. The goal is to uncover aspects of successful TGC and delineate the impact of differences in cohorts. METHODS A retrospective analysis was conducted using records from a 211-patient subset of the GluControl trial taken in Liege, Belgium, and 393 patients from Specialized Relative Insulin Nutrition Titration (SPRINT) in New Zealand. Specialized Relative Insulin Nutrition Titration targeted 4.0-6.0 mmol/liter, similar to the GluControl A (N = 142) target of 4.4-6.1 mmol/liter. The GluControl B (N = 69) target was 7.8-10.0 mmol/liter. Cohorts were matched by Acute Physiology and Chronic Health Evaluation II score and percentage males (p > .35); however, the GluControl cohort was slightly older (p = .011). Overall cohort and per-patient comparisons (median, interquartile range) are shown for (a) glycemic levels achieved, (b) nutrition from carbohydrate (all sources), and (c) insulin dosing for this analysis. Intra- and interpatient variability were examined using clinically validated model-based insulin sensitivity metric and its hour-to-hour variation. RESULTS Cohort blood glucose were as follows: SPRINT, 5.7 (5.0-6.6) mmol/liter; GluControl A, 6.3 (5.3-7.6) mmol/liter; and GluControl B, 8.2 (6.9-9.4) mmol/liter. Insulin dosing was 3.0 (1.0-3.0), 1.5 (0.5-3), and 0.7 (0.0-1.7) U/h, respectively. Nutrition from carbohydrate (all sources) was 435.5 (259.2-539.1), 311.0 (0.0-933.1), and 622.1 (103.7-1036.8) kcal/day, respectively. Median per-patient results for blood glucose were 5.8 (5.3-6.4), 6.4 (5.9-6.9), and 8.3 (7.6-8.8) mmol/liter. Insulin doses were 3.0 (2.0-3.0), 1.5 (0.8-2.0), and 0.5 (0.0-1.0) U/h. Carbohydrate administration was 383.6 (207.4-497.7), 103.7 (0.0-829.4), and 207.4 (0.0-725.8) kcal/day. Overall, SPRINT gave approximately 2x more insulin with a 3-4x narrower, but generally non-zero, range of nutritional input to achieve equally TGC with less hypoglycemia. Specialized Relative Insulin Nutrition Titration had much less hypoglycemia (<2.2 mmol/liter), with 2% of patients, compared to GluControl A (7.7%) and GluControl B (2.9%), indicating much lower variability, with similar results for glucose levels <3.0 mmol/liter. Specialized Relative Insulin Nutrition Titration also had less hyperglycemia (>8.0 mmol/liter) than groups A and B. GluControl patients (A+B) had a approximately 2x wider range of insulin sensitivity than SPRINT. Hour-to-hour variation was similar. Hence GluControl had greater interpatient variability but similar intrapatient variability. CONCLUSION Protocols that dose insulin blind to carbohydrate administration can suffer greater outcome glycemic variability, even if average cohort glycemic targets are met. While the cohorts varied significantly in model-assessed insulin resistance, their variability was similar. Such significant intra- and interpatient variability is a further significant cause and marker of glycemic variability in TGC. The results strongly recommended that TGC protocols be explicitly designed to account for significant intra- and interpatient variability in insulin resistance, as well as specifying or having knowledge of carbohydrate administration to minimize variability in glycemic outcomes across diverse cohorts and/or centers.
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Affiliation(s)
- Fatanah Suhaimi
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand;
| | - Aaron Le Compte
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand;
| | - Jean-Charles Preiser
- Department of Intensive Care, Centre Hospitalier Universitaire de Liege, Liege, Belgium;
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand;
| | - Paul Massion
- Department of Intensive Care, Centre Hospitalier Universitaire de Liege, Liege, Belgium;
| | - Regis Radermecker
- Department of Diabetology, Nutrition and Metabolic Disease, Centre Hospitalier Universitaire de Liege, Liege, Belgium;
| | - Christopher G. Pretty
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand;
| | - Jessica Lin
- Department of Medicine, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand;
| | - Thomas Desaive
- Cardiovascular Research Centre, University of Liege, Liege, Belgium
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand;
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Recommandations francophones pour le contrôle glycémique en réanimation (patients diabétiques et pédiatrie exclus). NUTR CLIN METAB 2009. [DOI: 10.1016/j.nupar.2009.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Adolph M, Heller AR, Koch T, Koletzko B, Kreymann KG, Krohn K, Pscheidl E, Senkal M. Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2009; 7:Doc22. [PMID: 20049078 PMCID: PMC2795378 DOI: 10.3205/000081] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 01/07/2023]
Abstract
The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (α-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25–40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7–1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.
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Affiliation(s)
- M Adolph
- Dept. of Anaesthesiology and Intensive Medicine, Eberhard-Karl University, Tuebingen, Germany
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Mao H, Wang H, Wang B, Liu X, Gao H, Xu M, Zhao H, Deng X, Lin D. Systemic Metabolic Changes of Traumatic Critically Ill Patients Revealed by an NMR-Based Metabonomic Approach. J Proteome Res 2009; 8:5423-30. [PMID: 19835422 DOI: 10.1021/pr900576y] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hailei Mao
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Huimin Wang
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Bin Wang
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Xia Liu
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Hongchang Gao
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Min Xu
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Hongsheng Zhao
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Xiaoming Deng
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
| | - Donghai Lin
- Affiliated Hospital of Nantong University, Nantong 226001, PR China, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, PR China, Changhai Hospital, Secondary Military Medical University, Shanghai 200433, PR China, Shanghai 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, PR China, and Xiamen University, Xiamen 361005, PR China
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Perman MI, Ciapponi A, Crivelli A, Garrote V, Loudet C, Perman G. Prescribed hypocaloric nutrition support for critically ill adults. Hippokratia 2009. [DOI: 10.1002/14651858.cd007867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Mario I Perman
- Hospital Italiano de Buenos Aires; Department of Medicine; Estomba 2040 Buenos Aires Capital Federal Argentina 1430
| | - Agustín Ciapponi
- Hospital Italiano de Buenos Aires; Family and Preventive Medicine Division; Independencia 1253 PB 'A' Buenos Aires Capital Federal Argentina 1099
| | - Adriana Crivelli
- Hospital HIGA San Martín; Unit of Nutrition Support and Malabsorptive Diseases; 64 Nº 1417 1/2 Dep. 2 La Plata Pcia. de Buenos Aires Argentina 1900
| | - Virginia Garrote
- Department of Education and Research, Hospital Italiano de Buenos Aires; Central Library; Gascón 450 Buenos Aires Argentina C1181ACH
| | - Cecilia Loudet
- Hospital HIGA San Martín; Intensive Care Medicine; 117, Nº 1467 La Plata Provincia Buenos Aires Argentina 1900
| | - Gastón Perman
- Hospital Italiano de Buenos Aires; Department of Medicine; Estomba 2040 Buenos Aires Capital Federal Argentina 1430
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Casaer MP, Mesotten D, Schetz MRC. Bench-to-bedside review: metabolism and nutrition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:222. [PMID: 18768091 PMCID: PMC2575562 DOI: 10.1186/cc6945] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Acute kidney injury (AKI) develops mostly in the context of critical illness and multiple organ failure, characterized by alterations in substrate use, insulin resistance, and hypercatabolism. Optimal nutritional support of intensive care unit patients remains a matter of debate, mainly because of a lack of adequately designed clinical trials. Most guidelines are based on expert opinion rather than on solid evidence and are not fundamentally different for critically ill patients with or without AKI. In patients with a functional gastrointestinal tract, enteral nutrition is preferred over parenteral nutrition. The optimal timing of parenteral nutrition in those patients who cannot be fed enterally remains controversial. All nutritional regimens should include tight glycemic control. The recommended energy intake is 20 to 30 kcal/kg per day with a protein intake of 1.2 to 1.5 g/kg per day. Higher protein intakes have been suggested in patients with AKI on continuous renal replacement therapy (CRRT). However, the inadequate design of the trials does not allow firm conclusions. Nutritional support during CRRT should take into account the extracorporeal losses of glucose, amino acids, and micronutrients. Immunonutrients are the subject of intensive investigation but have not been evaluated specifically in patients with AKI. We suggest a protocolized nutritional strategy delivering enteral nutrition whenever possible and providing at least the daily requirements of trace elements and vitamins.
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Affiliation(s)
- Michaël P Casaer
- Department of Intensive Care Medicine, University Hospital Leuven, Catholic University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomised controlled trial. Intensive Care Med 2008; 34:1411-20. [DOI: 10.1007/s00134-008-1072-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Accepted: 02/21/2008] [Indexed: 10/22/2022]
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Singh N. Are the fat really fit? Crit Care Med 2007; 35:1219-20; author reply 1220. [PMID: 17413803 DOI: 10.1097/01.ccm.0000259496.86478.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hasenboehler E, Williams A, Leinhase I, Morgan SJ, Smith WR, Moore EE, Stahel PF. Metabolic changes after polytrauma: an imperative for early nutritional support. World J Emerg Surg 2006; 1:29. [PMID: 17020610 PMCID: PMC1594568 DOI: 10.1186/1749-7922-1-29] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 10/04/2006] [Indexed: 12/11/2022] Open
Abstract
Major trauma induces marked metabolic changes which contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. The hypercatabolic state of polytrauma patients must be recognized early and treated by an appropriate nutritional management in order to avoid late complications. Clinical studies in recent years have supported the concept of "immunonutrition" for severely injured patients, which takes into account the supplementation of Ω-3 fatty acids and essential aminoacids, such as glutamine. Yet many aspects of the nutritional strategies for polytrauma patients remain controversial, including the exact timing, caloric and protein amount of nutrition, choice of enteral versus parenteral route, and duration. The present review will provide an outline of the pathophysiological metabolic changes after major trauma that endorse the current basis for early immunonutrition of polytrauma patients.
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Affiliation(s)
- Erik Hasenboehler
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Allison Williams
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Iris Leinhase
- Department of Trauma and Reconstructive Surgery, Charité University Medical Center, Campus Benjamin Franklin, 12200 Berlin, Germany
| | - Steven J Morgan
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Wade R Smith
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
| | - Philip F Stahel
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80204, USA
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Zauner A, Schneeweiss B, Kneidinger N, Lindner G, Zauner C. Weight-adjusted resting energy expenditure is not constant in critically ill patients. Intensive Care Med 2006; 32:428-34. [PMID: 16477414 DOI: 10.1007/s00134-005-0056-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/20/2005] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In critically ill patients, energy requirements are frequently calculated as a multiple of total body weight presuming a linear relationship between total body weight and resting energy expenditure (REE); however, it is doubtful if this estimation of energy needs should be applied to all patients, particularly to overweight patients, since adipose tissue has a low contribution to REE. This study was undertaken to test the hypothesis that REE adjusted for total body weight decreases with increasing body mass index in critically ill patients. Additionally, measured REE was compared with three predictive equations. DESIGN AND SETTING Clinical study in a university hospital intensive care unit. PATIENTS One hundred critically ill patients admitted to the intensive care unit. MEASUREMENTS AND RESULTS Patients were included into four groups according to their body mass index (normal weight, pre-obese, obese, and morbidly obese). Measured REE was assessed using indirect calorimetry. Energy needs were calculated using the basal metabolic rate, the Consensus Statement of the American College of Chest Physicians (REEacs), and 25[Symbol: see text]kcal/kg of ideal body weight (REEibw). Adjusted REE was 24.8 +/- 5.5 kcal/kg in normal weight, 22.0 +/- 3.7 kcal/kg in pre-obese, 20.4 +/- 2.6 kcal/kg in obese, and 16.3 +/- 2.3 kcal/kg in morbidly obese patients (p < 0.01). Basal metabolic rate underestimated measured REE in normal weight and pre-obese patients. REEacs and REEibw over- and underestimated measured REE in overweight patients, respectively. CONCLUSIONS Predictive equations were not able to estimate measured REE adequately in all the patients. Adjusted REE decreased with increasing body mass index; thus, a body mass index group-specific adaptation for the estimation of energy needs should be applied.
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Affiliation(s)
- Alexandra Zauner
- Medical University of Vienna, Intensive Care Unit, Department of Internal Medicine IV, Waehringer-Guertel 18-20, 1090, Vienna, Austria
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Zanello M, Di Mauro L, Vincenzi M. Therapeutic effects of artificial nutrition in intensive care patients: New insights. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cacc.2007.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Este trabalho é constituído de uma revisão de conceitos fundamentais e atualizados relacionados à terapia nutricional de crianças com câncer criticamente doentes. O objetivo principal desta revisão é discutir alterações nutricionais e metabólicas decorrentes dessa condição, bem como as indicações, recomendações, contra-indicações e complicações da terapia nutricional (nutrição enteral e parenteral) em pacientes com câncer. Este artigo aborda, de forma objetiva, a aplicação prática de alguns conceitos baseados em evidências científicas, e propõe algumas diretrizes para auxiliar na decisão da terapia nutricional no âmbito da vivência clínica. Conclui-se que há necessidade de maior incentivo ao desenvolvimento da ciência da terapia de suporte, como o tratamento das infecções, a terapia intensiva e a terapia metabólico-nutricional, para que se ampliem as possibilidades de cura de crianças e adolescentes com câncer.
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Abstract
PURPOSE OF REVIEW This review discusses the unique metabolic changes in critically ill obese patients and the challenges in estimating and providing them with nutritional support while in the intensive care unit. It provides some of the scientific data in support of and against hypocaloric, high-protein nutritional support in critically ill obese patients. RECENT FINDINGS The growing prevalence of obesity worldwide and particularly in the developed countries has resulted in concerns regarding the implementation of effective and specialized nutritional support for critically ill obese patients. The concerns arise from the limited data regarding the obese individual's response to various metabolic stresses, especially trauma and burns. There is continuous debate about the most appropriate method of calculating the critically ill obese patient's basic energy and calorie needs. SUMMARY Nutritional support of the critically ill obese represents a unique challenge but early administration of protein followed by carbohydrates and finally lipids can result in net protein anabolism and better glycemic control.
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Affiliation(s)
- Elamin M Elamin
- Department of Anesthesia and Medicine, Critical Care Medicine, University of South Florida, Department of Anesthesiology, Tampa, Florida 33612, USA.
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Burnham EL, Moss M, Ziegler TR. Myopathies in critical illness: characterization and nutritional aspects. J Nutr 2005; 135:1818S-1823S. [PMID: 15987872 DOI: 10.1093/jn/135.7.1818s] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Myopathies related to critical illness have received increasing recognition over the past decade and are common in patients even after a brief period in the intensive care unit. Recent studies have revealed that myopathies in the critically ill may in fact be more prevalent than neuropathies and that morbidity and mortality may be greater. Protein catabolism, an increase in urinary nitrogen loss, and muscle wasting are observed in critical illness myopathy. Muscle biopsies in critically ill patients demonstrate low glutamine levels, low protein/DNA levels, and high concentrations of extracellular water. The increased flux of glutamine in muscle in these patients is thought to be insufficient to meet the body's requirement for glutamine, and thus in critical illness this amino acid may be classified as "conditionally essential." Three subtypes of critical illness myopathy have been described that are often grouped together as acute quadriplegic myopathy: thick-filament myopathy, critical illness myopathy, and necrotizing myopathy. These can be differentiated based on clinical features and muscle biopsy. Treatments for critical illness myopathies range from primary prevention, i.e., avoiding myopathy-inducing drugs, to novel nutritional therapies, such as glutamine and glutathione supplementation. One should be particularly vigilant for the development of myopathies in critically ill alcoholic patients, who may have a chronic alcoholic myopathy at baseline. In the past decade, advances have been made in characterizing and identifying patients with myopathies due to critical illness. However, additional studies must be performed in order to develop appropriate therapies for this potentially devastating disorder.
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Affiliation(s)
- Ellen L Burnham
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, and the Division of Endocrinology and Metabolism, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Butler SO, Btaiche IF, Alaniz C. Relationship Between Hyperglycemia and Infection in Critically Ill Patients. Pharmacotherapy 2005; 25:963-76. [PMID: 16006275 DOI: 10.1592/phco.2005.25.7.963] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hyperglycemia is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including decreased polymorphonuclear leukocyte mobilization, chemotaxis, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose-dependent organs, but also because the true significance of short-term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection-related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized.
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Affiliation(s)
- Simona O Butler
- Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbour, Michigan 48109, USA
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Abstract
This article discusses metabolic, electrolyte, and nutritional concerns in critical illness.
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Affiliation(s)
- Jean-Philippe Lafrance
- Nephrology and Critical Care, Maisonneuve-Rosemont Hospital, University of Montreal, 5415 de l'Assomption, Montreal, Quebec H1T 2M4, Canada
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Bardutzky J, Georgiadis D, Kollmar R, Schwarz S, Schwab S. Energy demand in patients with stroke who are sedated and receiving mechanical ventilation. J Neurosurg 2004; 100:266-71. [PMID: 15086234 DOI: 10.3171/jns.2004.100.2.0266] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was 1) to determine the total energy expenditure (TEE) in patients with acute stroke who are sedated and receiving mechanical ventilation; and 2) to compare the TEE between patients with ischemic and hemorrhagic stroke. METHODS Thirty-four consecutive nonseptic patients with stroke requiring sedation and mechanical ventilation were prospectively examined; 13 of the patients had experienced spontaneous intracerebral hemorrhage and 21 cerebral ischemia of the middle cerebral artery territory. The TEE was evaluated using continuous indirect calorimetry during the first 5 days after admission to the intensive care unit. The serum albumin concentration was determined on admission and on Day 5. The TEE varied from 1560 +/- 240 to 1623 +/- 251 kcal/day. A highly significant correlation between the TEE and the basal energy expenditure (BEE), as predicted using the Harris-Benedict equation, was observed in both groups. No significant differences in the TEE were detected between the two groups or among the different study days. CONCLUSIONS A highly significant correlation was found between the TEE and the predicted BEE in patients with acute stroke who have been sedated and have received mechanical ventilation. No significant differences were observed between patients with hemorrhagic and ischemic stroke. Further studies are needed to evaluate the effect of tailored feeding on clinical outcome in these patients.
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Thavasothy M. Trauma and critical care II: abdominal trauma. TRAUMA-ENGLAND 2004. [DOI: 10.1191/1460408604ta300oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Intensivist is involved in the management of patients with abdominal trauma from their original presentation in the Emergency Department, where assessment of haemodynamic stability will influence the decision to opt for surgical, as opposed to conservative, treatment. Subsequently a large percentage of these patients, particularly those with blunt abdominal injuries, may require level 2 (HDU) or level 3 (ITU) care to monitor progress, correct any coagulopathy, maintain organ support and allow for early recognition of the major sequelae of such injuries. These include severe sepsis, trauma-related pancreatitis and the abdominal compartment syndrome. All are associated with significant morbidity and mortality, usually many days or weeks after admission. This article, in addition to reviewing some of the contributory factors involved in trauma-related coagulopathy, will discuss these sequelae and some of the concepts and strategies currently used in their management. It also includes an overview of therapies used in a critical care setting to maintain nutrition and renal homeostasis in the event of sequential organ failure.
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Träger K, DeBacker D, Radermacher P. Metabolic alterations in sepsis and vasoactive drug-related metabolic effects. Curr Opin Crit Care 2003; 9:271-8. [PMID: 12883281 DOI: 10.1097/00075198-200308000-00004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The main clinical characteristics of sepsis and septic shock are derangements of cardiocirculatory and respiratory function. Additionally, profound alterations in metabolic pathways occur leading to hypermetabolism, enhanced energy expenditure, and insulin resistance. The clinical hallmarks are hyperglycemia, hyperlactatemia, and enhanced protein catabolism. These metabolic alterations are even more pronounced during sepsis as a result of cytokine release and subsequent induction of inflammatory pathways. Increased oxygen demands from mitochondrial oxygen utilization and oxygen consumption related to oxygen radical formation may contribute to hypermetabolism. In addition, mitochondrial dysfunction with impaired cellular respiration may be present. Mainstay therapeutic interventions for hemodynamic stabilization are adequate volume resuscitation and vasoactive agents, which, however, have additional impact on metabolic activity. Therefore, beyond hemodynamic effects, specific drug-related metabolic alterations need to be considered for optimal treatment during sepsis. This review gives an overview of the typical metabolic alterations during sepsis and septic shock and highlights the impact of vasoactive therapy on metabolism.
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Affiliation(s)
- Karl Träger
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Germany.
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