Bio-ecological control of perioperative and ITU morbidity

The Role of Modified Early Warning Score (MEWS) in the Prognosis of Acute Pancreatitis

Objectives

Modified Early Warning Score (MEWS) is a reliable, safe, instant, and inexpensive score for prognosticating patients with acute pancreatitis (AP) due to its ability to reflect ongoing changes of the systemic inflammatory response syndrome associated with AP. Our study sought to determine an optimal MEWS value in predicting severity in AP and determine its accuracy in doing so.

Methods

Patients diagnosed with AP and admitted to a single institution were analyzed to determine the value of MEWS in identifying severe AP (SAP). The highest MEWS (hMEWS) score for the day and the mean of all the scores of a given day (mMEWS) were determined for each day. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were calculated for the optimal MEWS values obtained.

Results

Two hundred patients were included in the study. The data suggested that an hMEWS value > 2 on day one is most accurate in predicting SAP, with a specificity of 90.8% and PPV of 83.3%. An mMEWS of > 1.2 on day two was the most accurate in predicting SAP, with a sensitivity of 81.2%, specificity of 76.6%, PPV of 69.8%, and NPV of 85.9%. These were found to be more accurate than previous studies.

Conclusions

MEWS provides a novel, easy, instant, repeatable, and reliable prognostic score that is comparable, if not superior, to existing scoring systems. However, its true value may lie in its use in resource-limited settings such as primary health care centers.

Probiotics for patients with hepatic encephalopathy

BACKGROUND

Hepatic encephalopathy is a disorder of brain function as a result of liver failure and/or portosystemic shunt. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning and represent a significant burden on health care resources. Probiotics are live microorganisms, which when administered in adequate amounts may confer a health benefit on the host.

OBJECTIVES

To quantify the beneficial and harmful effects of any probiotic in any dosage, compared with placebo or no intervention, or with any other treatment for patients with any grade of acute or chronic hepatic encephalopathy as assessed from randomised trials.

SEARCH METHODS

We searched the The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, conference proceedings, reference lists of included trials and the WHO international clinical trials registry until April 2011 registry platform to identify new and ongoing trials.

SELECTION CRITERIA

We included randomised trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in patients with hepatic encephalopathy.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed the risk of bias of the included trials and extracted data on relevant outcomes, with differences resolved by consensus. We conducted random-effects model meta-analysis due to obvious heterogeneity of patients and interventions. A P value of 0.05 or less was defined as significant. Dichotomous outcomes are expressed as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We included seven trials of which 550 participants were randomised. Four of the seven trials compared a probiotic with placebo or no treatment in 245 participants, another trial compared a probiotic with lactulose in 40 participants , and the remaining two trials compared a probiotic with both placebo and lactulose in 265 participants. Each trial used different types of probiotics. Duration of administration of the experimental intervention varied from 10 days to 180 days. Two trials were industry funded, and five were unclear about origin of funding. All trials had high risk of bias. When probiotics were compared with no treatment, there was no significant difference in all-cause mortality (2 trials, 105 participants; 1/57 (2%) versus 1/48 (2%): RR 0.72; 95% CI 0.08 to 6.60), lack of recovery (4 trials, 206 participants; 54/107 (50%) versus 68/99 (69%): RR 0.72; 95% CI 0.49 to 1.05), adverse events (3 trials, 145 participants; 2/77 (3%) versus 6/68 (9%): RR 0.34; 95% CI 0.08 to 1.42), quality of life (1 trial, 20 participants contributed to the physical quality of life measurement, 20 participants contributed to the mental quality of life: MD Physical 0.00; 95% CI -5.47 to 5.47; MD Mental 4.00; 95% CI -1.82 to 9.82), or change of/or withdrawal from treatment (3 trials, 175 participants; 11/92 (12%) versus 7/83 (8%): RR 1.28; 95% CI 0.52 to 3.19). No trial reported sepsis or duration of hospital stay as an outcome. Plasma ammonia concentration was significantly lower for participants treated with probiotic at one month (3 trials, 226 participants: MD -2.99 μmol/L; 95% CI -5.70 to -0.29) but not at two months (3 trials, 181 participants: MD -1.82 μmol/L; 95% CI -14.04 to 10.41). Plasma ammonia decreased the most in the participants treated with probiotic at three months (1 trial, 73 participants: MD -6.79 μmol/L; 95% CI -10.39 to -3.19). When probiotics were compared with lactulose no trial reported all-cause mortality, quality of life, duration of hospital stay, or septicaemia. There were no significant differences in lack of recovery (3 trials, 173 participants; 47/87 (54%) versus 44/86 (51%): RR 1.05; 95% CI 0.75 to 1.47), adverse events (2 trials, 111 participants; 3/56 (5%) versus 6/55 (11%): RR 0.57; 95% CI 0.06 to 5.74), change of/or withdrawal from treatment at one month (3 trials, 190 participants; 8/95 (8%) versus 7/95 (7%): RR 1.10; 95% CI 0.40 to 3.03), plasma ammonia concentration (2 trials, 93 participants: MD -6.61 μmol/L; 95% CI -30.05 to 16.84), or change in plasma ammonia concentration (1 trial, 77 participants: MD 1.16 μmol/L; 95% CI -1.96 to 4.28).

AUTHORS' CONCLUSIONS

The trials we located suffered from a high risk of systematic errors ('bias') and high risk of random errors ('play of chance'). While probiotics appear to reduce plasma ammonia concentration when compared with placebo or no intervention, we are unable to conclude that probiotics are efficacious in altering clinically relevant outcomes. Demonstration of unequivocal efficacy is needed before probiotics can be endorsed as effective therapy for hepatic encephalopathy. Further randomised clinical trials are needed.

Perioperative synbiotic treatment to prevent infectious complications in patients after elective living donor liver transplantation: a prospective randomized study

BACKGROUND

Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT).

METHODS

Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group.

RESULTS

Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp (P = .033 vs BLO group). No other type of complication showed any difference between the groups.

CONCLUSIONS

Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.

The role of prebiotics and synbiotics in critically ill patients

PURPOSE OF REVIEW

To examine current knowledge regarding the role of prebiotics in critical illness when administered singly or in combinations with probiotics (synbiotics).

RECENT FINDINGS

Recent experimental and clinical studies support the fact that bioecological intestinal control with early enteral nutrition enriched with synbiotics may reduce systemic inflammation, improve the immunological status of the intestinal mucosa and help prevent infections in critically ill patients. Three prebiotics, oligofructose, galactooligosaccharides and lactulose are able to modify the balance of intestinal microbiota. It appears that treatment with synbiotics during critical illness should restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation. Only data from small trials are currently available to support use of prebiotics and synbiotics in the treatment of different clinical scenarios. However, in some critical conditions, this supplementation has so far not been effective.

SUMMARY

Numerous questions about the molecular mechanisms of action or clinical indications of prebiotics remain unanswered. Large, randomized, multicentre trials are necessary to precisely define the role of prebiotics as therapeutic agents in critical illness. These trials must identify clinically significant improvements in relevant clinical endpoints before any large-scale usage is advocated for critical illness.

Eubacterium plautii infection in a kidney transplant recipient: a noteworthy case of pleural effusion and fever

We report a noteworthy case of Eubacterium plautii infection after kidney transplantation. Our 33-yr-old transplant recipient received standard care; his post-transplant course was uneventful. However, on day 44 he underwent an emergency laparotomy for perforation of the ileum. He was initially treated with ceftazidime, fluconazole and metronidazole, but his fever persisted, so he was switched to meropenem and vancocin. We could not find any cause for his infection. On day 70, his temperature normalized. On day 75, he developed severe leukopenia (280 cell/mL). His cytomegalovirus-DNA test result was negative, so all immunosuppressants, except for prednisone, were stopped; instead, antibiotic prophylaxis was started, using caspofungin, trimethoprim-sulfamethoxazole and ciprofloxacin. On day 83, he underwent percutaneous drainage of massive left pleural effusion. We repeatedly cultured the pleural liquid, but it was not till three wk later that we were finally able to identify the causative organism. We hypothesize that the microorganism - which normally resides on the surface of the intestinal lumen - entered the bloodstream via bacterial translocation, eventually colonizing the pleurae. This translocation was favored by our patient poor clinical condition, his immunosuppressive treatment and his heavy antibiotherapy. Our experience highlights the need for wiser use of antibiotics in transplant recipients.

Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution: A prospective randomized double-blind study

AIM: To compare the beneficial effects of early enteral nutrition (EN) with prebiotic fiber supplementation in patients with severe acute pancreatitis (AP).

METHODS: Thirty consecutive patients with severe AP, who required stoppage of oral feeding for 48 h, were randomly assigned to nasojejunal EN with or without prebiotics. APACHE II score, Balthazar’s CT score and CRP were assessed daily during the study period.

RESULTS: The median duration of hospital stay was shorter in the study group [10 ± 4 (8-14) d vs 15 ± 6 (7-26) d] (P < 0.05). The median value of days in intensive care unit was also similar in both groups [6 ± 2 (5-8) d vs 6 ± 2 (5-7) d]. The median duration of EN was 8 ± 4 (6-12) d vs 10 ± 4 (6-13) d in the study and control groups, respectively (P > 0.05). Deaths occurred in 6 patients (20%), 2 in the study group and 4 in the control group. The mean duration of APACHE II normalization (APACHE II score < 8) was shorter in the study group than in the control group (4 ± 2 d vs 6.5 ± 3 d, P < 0.05). The mean duration of CRP normalization was also shorter in the study group than in the control group (7 ± 2 d vs 10 ± 3 d, P < 0.05).

CONCLUSION: Nasojejunal EN with prebiotic fiber supplementation in severe AP improves hospital stay, duration nutrition therapy, acute phase response and overall complications compared to standard EN therapy.

Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients

BACKGROUND

Since the hepatosplanchnic region plays a central role in development of multiple-organ failure and infections in critically ill trauma patients, this study focuses on the influence of glutamine, peptide, and synbiotics on intestinal permeability and clinical outcome.

METHODS

One hundred thirteen multiple injured patients were prospectively randomized into 4 groups: group A, glutamine; B, fermentable fiber; C, peptide diet; and D, standard enteral formula with fibers combined with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula containing live lactobacilli and specific bioactive fibers. Intestinal permeability was evaluated by measuring lactulose-mannitol excretion ratio on days 2, 4, and 7.

RESULTS

No differences in days of mechanical ventilation, intensive care unit stay, or multiple-organ failure scores were found between the patient groups. A total of 51 infections, including 38 pneumonia, were observed, with only 5 infections and 4 pneumonias in group D, which was significantly less than combined infections (p = .003) and pneumonias (p = .03) in groups A, B, and C. Intestinal permeability decreased only in group D, from 0.148 (0.056-0.240) on day 4 to 0.061 (0.040-0.099) on day 7; (p < .05). In group A, the lactulose-mannitol excretion ratio increased significantly (p < .02) from 0.050 (0.013-0.116) on day 2 to 0.159 (0.088-0.311) on day 7. The total gastric retention volume in 7 days was 1150 (785-2395) mL in group D, which was significantly more than the 410 (382-1062) mL in group A (p < .02), and 620 (337-1190) mL in group C (p < .03).

CONCLUSIONS

Patients supplemented with synbiotics did better than the others, with lower intestinal permeability and fewer infections.

Aggressive management of surgical emergencies

Increasing evidence suggests that two factors significantly influence outcome in a surgical emergency - premorbid health and the degree of inflammation during the first 24 h following trauma. Repeat observations suggest that the depth of post-trauma immunoparalysis reflects the height of early inflammatory response. Administration to surgical emergencies, as was routine in the past, of larger amounts of fluid and electrolytes, fat, sugar and nutrients seems counterproductive as it increases immune dysfunction, impairs resistance to disease and, in fact, increases morbidity. Instead, strong efforts should be made to limit the obvious superinflammation, which occurs during the first 24 h after trauma and, thereby, reduce the subsequent immunoparalysis. Several approaches show efficacy in limiting early superinflammation such as strict control of blood glucose, avoidance of stored blood when possible, supply of antioxidants, live lactic acid bacteria and plant fibres. This review focuses mainly on use of live lactic acid bacteria and plant fibres, often called synbiotics. Encouraging experience is reported from clinical trials in liver transplantation, severe pancreatitis and extensive trauma. Immediate control of inflammation by enteral nutrition and supply of antioxidants, lactic acid bacteria and fibres is facilitated by feeding tubes, introduced as early as possible on arrival at the hospital.

Bioecological control of inflammatory bowel disease

It is today generally accepted, that the intestinal bacterial flora is deeply involved in the pathogenesis of human inflammatory bowel diseases (IBDs), although the exact presence of unwanted or lack of specific crucial bacteria are not yet known. Westerners lack to large extent important immunomodulatory and fibre-fermenting lactic acid bacteria (LAB), bacteria which are present in all with a more primitive rural lifestyle. Acute reduction of flora is observed in disease, including IBD, as well as in mental and physical stress. Some observations suggest the mucosa has lost its ability of holding back the pathogenic flora and prevent close contacts between resident microflora and the epithelial surface. Among the manifestations of IBD are increased inflammation and coagulability, impaired cellular membrane function, exaggerated nitric oxide production and impaired short-chain fatty acid production. Animal studies suggest, in addition to reduced flora, an intimate association with immunostimulatory DNA, malfunctioning trifoil factors, increased splanchnic metabolism and reduced availability of natural antioxidants. Treatment with plant fibres, antioxidants and sometimes probiotics have had limited success. The most dramatic effects are seen in the few cases where total faecal replacement (TFR) has been tried. The general experience this far is that the best effects are obtained with compositions of probiotics rather than with single LAB treatments.

The role of probiotics in gastrointestinal surgery

PURPOSE OF REVIEW

Postoperative complications in gastrointestinal elective surgery have been described as low. In certain circumstances, however, such as those including high-risk patients, the incidence is higher. In such situations, bacteremia and infectious complications may be caused by translocation of either gastrointestinal bacteria or its toxins as the result of bacterial overgrowth, loss of intestinal epithelial integrity, or immunologic compromising of the host. Attempts should be made to reduce the impact of these factors. Probiotics, which confer to the host health benefits similar to those offered by a balanced indigenous microbiota, are thought to act through a variety of mechanisms including the competition with potential pathogens for nutrients or enterocyte adhesion sites, degradation of toxins, production of antimicrobial factors, and local and systemic immunomodulation.

RECENT FINDINGS

Recent studies have shown that probiotics play a role in decreasing postoperative complications in patients undergoing major gastrointestinal operations.

SUMMARY

Considering the mechanisms of action of probiotics in the gastrointestinal tract, mainly in the intestine, evidence strongly suggests that the use of these microorganisms might positively affect the complication rate in patients undergoing surgery on the gastrointestinal tract.

Bioecologic Control of Inflammation and Infection in Critical Illness

Surgical and medical emergencies and treatments are still affected by an unacceptably high rate of morbidity and mortality. Sepsis is the most common medical and surgical complication and the tenth most common cause of death. Antibiotics and antagonists and inhibitors of proinflammatory cytokines have not met expectations. Selective bowel decontamination is no longer a treatment option. After more than 30 randomized clinical trials and 30 years of dedicated efforts to combat sepsis by the use of various combinations of antibiotics, we seem ready to conclude that the vigorous use of antibiotics does not significantly reduce mortality in critically ill patients. Side effects and price constitute important obstacles, especially when it comes to use of cytokine antagonists and inhibitors.

Intestinal failure

PURPOSE OF REVIEW

The gastrointestinal tract plays a major role in critical illness. We will review four common problem areas pertaining to the gut and abdominal compartment that intensivists managing critically ill patients must deal with on an everyday basis.

RECENT FINDINGS

In the area of enteral nutrition, there have been concerns that early feeding in hemodynamically unstable patients might cause bowel infarction by increasing the gut oxygen consumption beyond splanchnic oxygen delivery. The most recent data suggest that early enteral feeding, even when patients are receiving vasopressors, is safe and may actually protect the gut by increasing gut perfusion. Although there are no new treatments for ileus, in most critically ill patients ileus primarily affects the stomach and large intestine, and most patients who are diagnosed with ileus may still be fed enterally as long as they are fed distal to the stomach. Diarrhea is a common occurrence in the intensive care unit, particularly in patients who are being fed enterally. Of most import is the realization that Clostridium difficile infection is ubiquitous and must be considered in virtually every case of diarrhea. Abdominal compartment syndrome is usually a result of shock, and its resuscitation with increased intra-abdominal pressure results in many untoward hemodynamic and respiratory events. Early recognition and treatment seem to be associated with improved outcome.

SUMMARY

Continued progress in the areas of optimal nutritional support, understanding the implications of alterations in immune function of the gut, and the avoidance of such morbid complications as abdominal compartment syndrome are expected.

Bio-ecological control of acute pancreatitis: the role of enteral nutrition, pro and synbiotics

PURPOSE OF REVIEW

Increasing knowledge, both experimental and clinical, supports the fact that early and aggressive enteral nutrition has the capacity to reduce superinflammation and prevent infections in severe acute pancreatitis. Clearly, the main role of enteral nutrition is to boost the immune system, and not, at least initially, to provide calories. Whereas enteral nutrition improves, parenteral nutrition reduces immune functions.

RECENT FINDINGS

The content of enteral nutrition solutions is more important than the route of administration per se. Antioxidants, plant fibres and live lactic acid bacteria are especially important for boosting the immune system. Recent studies support the fact that enteral nutrition and the supply of fibres and live lactic acid bacteria may significantly reduce the rate of infections. So far none of the treatments has been able to reduce the incidence of the systemic inflammatory response syndrome and multiorgan dysfunction syndrome. A recent unpublished study indicates, however, that the systemic inflammatory response syndrome and multiorgan dysfunction syndrome can also be reduced if much higher doses of lactic acid bacteria and a combination of several bioactive lactic acid bacteria are used (synbiotics).

SUMMARY

Immunosupporting enteral nutrition with synbiotics is an important tool to control superinflammation and infection, and might also reduce the multiorgan dysfunction syndrome and systemic inflammatory response syndrome. It is essential that it is supplied early, if possible in the emergency room. New autopositioning regurgitation-resistant feeding tubes are available to facilitate such a policy.

Prebiotic ingestion does not improve gastrointestinal barrier function in burn patients

Prebiotics increase intestinal levels of health-promoting bacteria implicated in decreasing pathogen colonization, stimulating immune functions and stabilizing gut barrier functions, parameters which are altered in burn patients. We propose that regular intake of a prebiotic, oligofructose (OF), might help to improve the altered gastrointestinal (GI) permeability observed in burn patients. A randomized, double-blind, controlled clinical trial was carried out in 41 burn patients (mean burn surface area=17.1+/-8.2%) who ingested daily 6 g of oligofructose (OF group) or sucrose as placebo (Control group) during 15 days. Gastrointestinal permeability to sucrose and lactulose/mannitol (L/M) was evaluated on days 1 (before treatment) 3, 7, 14 and 21. A permeability test was also performed in 18 healthy subjects as controls. Thirty-one patients completed the protocol (dropout rate=24.4%). Healthy subjects had a basal sucrose excretion of 21.3 mg (14.0-32.5 mg) and a basal L/M ratio of 0.017% (0.009-0.022%). Sucrose excretion increased 5-fold and L/M ratio 4.4-fold in burn patients on day 1 and these high levels of marker excretion decreased significantly throughout the study (p=0.016 and 0.000001, respectively). No differences between the OF and Control groups were observed for sucrose excretion or L/M ratio. In conclusion, the normalization of gastrointestinal permeability is not accelerated by prebiotic intake.