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Hajjar J, Dziegielewski C, Dickson S, Simpson A, Kyeremanteng K. The role of low-carbohydrate diets in the intensive care unit. Nutr Health 2023; 29:377-381. [PMID: 36591890 DOI: 10.1177/02601060221149088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Low-carbohydrate, high-fat (LCHF) nutrition therapy is characterized by carbohydrates comprising <26% of the daily caloric intake and a higher proportion of fat. LCHF therapies reduce exogenous glucose load, improve glycemic control, decrease inflammation, and improve clinical outcomes such as respiratory function. Given the altered metabolism in critically ill patients, LCHF nutrition therapy may be especially beneficial as it enables the conservation of protein and glucose for metabolic roles beyond energy use. In critical illness, LCHF diets have the potential to reduce hyperglycemia, improve ventilation, decrease hospital length of stay and reduce hospital costs. The purpose of this commentary piece is to describe LCHF nutrition therapy, summarize its impact on health outcomes, and discuss its role in the intensive care unit (ICU). Additional research on the effects of LCHF nutrition therapy on critically ill patients is warranted, including a focus on COVID-19.
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Affiliation(s)
- Julia Hajjar
- Institut du Savoir Montfort, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Sarah Dickson
- Institut du Savoir Montfort, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Allison Simpson
- Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Institut du Savoir Montfort, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
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2
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Vázquez-Serrano JI, Peimbert-García RE, Cárdenas-Barrón LE. Discrete-Event Simulation Modeling in Healthcare: A Comprehensive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12262. [PMID: 34832016 PMCID: PMC8625660 DOI: 10.3390/ijerph182212262] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/26/2022]
Abstract
Discrete-event simulation (DES) is a stochastic modeling approach widely used to address dynamic and complex systems, such as healthcare. In this review, academic databases were systematically searched to identify 231 papers focused on DES modeling in healthcare. These studies were sorted by year, approach, healthcare setting, outcome, provenance, and software use. Among the surveys, conceptual/theoretical studies, reviews, and case studies, it was found that almost two-thirds of the theoretical articles discuss models that include DES along with other analytical techniques, such as optimization and lean/six sigma, and one-third of the applications were carried out in more than one healthcare setting, with emergency departments being the most popular. Moreover, half of the applications seek to improve time- and efficiency-related metrics, and one-third of all papers use hybrid models. Finally, the most popular DES software is Arena and Simul8. Overall, there is an increasing trend towards using DES in healthcare to address issues at an operational level, yet less than 10% of DES applications present actual implementations following the modeling stage. Thus, future research should focus on the implementation of the models to assess their impact on healthcare processes, patients, and, possibly, their clinical value. Other areas are DES studies that emphasize their methodological formulation, as well as the development of frameworks for hybrid models.
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Affiliation(s)
- Jesús Isaac Vázquez-Serrano
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
| | - Rodrigo E. Peimbert-García
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
- School of Engineering, Macquarie University, Sydney, NSW 2109, Australia
| | - Leopoldo Eduardo Cárdenas-Barrón
- School of Engineering and Sciences, Tecnologico de Monterrey, Monterrey 64849, Northeast Nuevo Leon, Mexico; (J.I.V.-S.); (L.E.C.-B.)
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3
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Bechtold ML, Regunath H, Tyler R, Guenter P, Barrocas A, Collins NA. Impact of a nutrition support therapy on hospital-acquired infections: A value analysis. Nutr Clin Pract 2021; 36:1034-1040. [PMID: 34245487 DOI: 10.1002/ncp.10729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed. METHODS An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted. RESULTS The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs. CONCLUSION Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.
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Affiliation(s)
- Matthew L Bechtold
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Hariharan Regunath
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Renay Tyler
- Ambulatory Services, University of Maryland, Baltimore, Maryland
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland
| | - Albert Barrocas
- Department of Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Nilsa A Collins
- Clinical Integration Programs, WellStar Clinical Partners, Marietta, Georgia
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4
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Martindale RG, Berlana D, Boullata JI, Cai W, Calder PC, Deshpande GH, Evans D, Garcia-de-Lorenzo A, Goulet OJ, Li A, Mayer K, Mundi MS, Muscaritoli M, Pradelli L, Rosenthal M, Seo JM, Waitzberg DL, Klek S. Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition". JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S7-S20. [PMID: 32049392 DOI: 10.1002/jpen.1746] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/24/2019] [Accepted: 10/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). METHODS The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. RESULTS The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. CONCLUSIONS This article provides a set of expert consensus statements to complement formal PN guideline recommendations.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - David Berlana
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus and Department of Nutrition, University of Barcelona, Barcelona, Spain
| | - Joseph I Boullata
- Department of Nutrition Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Cai
- Department of Pediatric Surgery, Division of Pediatric Gastroenterology and Nutrition, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Girish H Deshpande
- Neonatal NICU, Nepean Hospital, Kingswood, NSW, Australia.,Sydney Medical School, Nepean, University of Sydney, Australia
| | - David Evans
- Department of Surgery, Ohio State University Medical Center, Columbus, Ohio, USA
| | | | - Olivier J Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, National Reference Center for Rare Digestive Diseases, Hospital Necker-Enfants Malades, University of Paris-Descartes, Paris, France
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Konstantin Mayer
- Vidia Kliniken Karlsruhe, Medizinische Klinik IV, Karlsruhe, Germany
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Martin Rosenthal
- Department of Surgery, Division of Trauma and Acute Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jeong-Meen Seo
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dan L Waitzberg
- Department of Gastroenterology, Lim 35, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Stanislaw Klek
- Department of General and Oncology Surgery, Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
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5
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Mayer K, Klek S, García-de-Lorenzo A, Rosenthal MD, Li A, Evans DC, Muscaritoli M, Martindale RG. Lipid Use in Hospitalized Adults Requiring Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S28-S38. [PMID: 32049396 DOI: 10.1002/jpen.1733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/13/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
Abstract
In hospitalized patients, lipid emulsions are an integral part of balanced parenteral nutrition. Traditionally, a single lipid source, soybean oil, has been given to patients and was usually regarded as just a source of energy and to prevent essential fatty-acid deficiency. However, mixtures of different lipid emulsions have now become widely available, including mixtures of soybean oil, medium-chain triglycerides, olive oil, and fish oil. Fish oil is high in the ω-3 polyunsaturated fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). There is a growing body of evidence that these ω-3 fatty acids can exert beneficial immunomodulatory, anti-inflammatory, and inflammation-resolution effects across a wide range of patient groups including surgical, cancer, and critically ill patients. At least in part, these effects are realized via potent specialized pro-resolution mediators (SPMs). Moreover, parenteral nutrition including ω-3 fatty acids can result in additional clinical benefits over the use of standard lipid emulsions, such as reductions in infection rates and length of hospital and intensive care unit stay. Clinical and experimental evidence is reviewed regarding lipid emulsion use in a variety of hospitalized patient groups, including surgical, critically ill, sepsis, trauma, and acute pancreatitis patients. Practical aspects of lipid emulsion use in critically ill patients are also considered, such as how to determine and fulfill energy expenditure, how and when to consider parenteral nutrition, duration of infusion, and safety monitoring.
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Affiliation(s)
- Konstantin Mayer
- ViDia Kliniken Karlsruhe, Medizinische Klinik IV, Karlsruhe, Germany
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Martin D Rosenthal
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - David C Evans
- Department of Surgery, Ohio State University Medical Center, Columbus, Ohio, USA
| | | | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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6
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Pradelli L, Klek S, Mayer K, Omar Alsaleh AJ, Rosenthal MD, Heller AR, Muscaritoli M. Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US. JPEN J Parenter Enteral Nutr 2020; 45:999-1008. [PMID: 32713007 PMCID: PMC8451886 DOI: 10.1002/jpen.1972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 01/17/2023]
Abstract
Background ω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US. Methods This pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses. Results Overall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively). Conclusion This cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.
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Affiliation(s)
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Konstantin Mayer
- ViDia Hospitals, Department of Pulmonary and Sleep Medicine, Karlsruhe, Germany
| | | | - Martin D Rosenthal
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University of Augsburg, Augsburg, Germany
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7
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Pradelli L, Muscaritoli M, Klek S, Martindale RG. Pharmacoeconomics of Parenteral Nutrition with ω‐3 Fatty Acids in Hospitalized Adults. JPEN J Parenter Enteral Nutr 2020; 44 Suppl 1:S68-S73. [DOI: 10.1002/jpen.1775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/11/2019] [Accepted: 12/10/2019] [Indexed: 12/18/2022]
Affiliation(s)
| | | | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit Stanley Dudrick's Memorial Hospital Skawina Poland
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8
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Tyler R, Barrocas A, Guenter P, Araujo Torres K, Bechtold ML, Chan L, Collier B, Collins NA, Evans DC, Godamunne K, Hamilton C, Hernandez BJD, Mirtallo JM, Nadeau WJ, Partridge J, Perugini M, Valladares A. Value of Nutrition Support Therapy: Impact on Clinical and Economic Outcomes in the United States. JPEN J Parenter Enteral Nutr 2020; 44:395-406. [DOI: 10.1002/jpen.1768] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Renay Tyler
- University of Maryland Medical Center Baltimore Maryland USA
| | | | - Peggi Guenter
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
| | | | - Matthew L. Bechtold
- Division of Gastroenterology & HepatologyDepartment of Medicine University Hospital & Clinics Columbia Missouri USA
| | - Lingtak‐Neander Chan
- Department of PharmacyInterdisciplinary FacultyNutritional Sciences ProgramUniversity of Washington Seattle Washington USA
| | - Bryan Collier
- Virginia Tech Carilion School of Medicine Roanoke Virginia USA
| | - Nilsa A. Collins
- Clinical Integration ProgramsWellStar Clinical Partners Marietta Atlanta Georgia USA
| | - David C. Evans
- Ohio Health Trauma and Surgical Services Columbus Ohio USA
| | | | - Cindy Hamilton
- Digestive Disease and Surgery Institute Cleveland Clinic Cleveland Ohio USA
| | | | - Jay M. Mirtallo
- Clinical Practice, Quality, and AdvocacyAmerican Society for Parenteral Nutrition Silver Spring Maryland USA
- The Ohio State UniversityCollege of Pharmacy Columbus Ohio USA
| | | | - Jamie Partridge
- Field Health Economics and Outcomes ResearchBayer Pharmaceuticals Whippany New Jersey USA
| | - Moreno Perugini
- Global Head of Medical Affairs & Marketing AccessNestlé Health Science Bridgewater New Jersey USA
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9
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Uhlig C, Rössel T, Denz A, Seifert S, Koch T, Heller AR. Effects of a metabolic optimized fast track concept (MOFA) on bowel function and recovery after surgery in patients undergoing elective colon or liver resection: a randomized controlled trial. BMC Anesthesiol 2019; 19:156. [PMID: 31421670 PMCID: PMC6698338 DOI: 10.1186/s12871-019-0823-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/06/2019] [Indexed: 12/26/2022] Open
Abstract
Background Enhanced recovery after surgery programs (ERAS) using thoracic epidural anesthesia and perioperative patient conditioning with omega-3 fatty acids (n3FA), glucose control (GC) and on-demand fluid therapy, respectively, showed beneficial effects. In the MOFA- study these components were used together in patients undergoing colon or liver surgery. We hypothesized that the use of a perioperative MOFA program improves intestine function represented as time to the first postoperative bowel movement in adult patients compared to standard ERAS. Methods After BfArM and IRB approval 100 patients were enrolled in this prospective randomized controlled trial. All patients received ERAS therapy (control). In addition, the MOFA group received 0.2 g/kg fish oil (Omegaven®), preoperatively, followed by a 48 h continuous infusion of 0.2 g/kg/d n3FA; and GC was kept below < 8 mmol/L. Pre- and postoperatively energy drinks were administered. Results As compared to control group the MOFA concept resulted in an earlier onset of flatulence by 14 h (46.6 ± 25.7, 32.0 ± 17.9, p = 0.030, hours, control vs. MOFA, respectively). Effects on onset of bowel movement were not observed (74.5 ± 30.4, 66.4 ± 29.2, p = 0.163, hours, control vs. MOFA, respectively). The disease severity (SAPS II score; p = 0.720) as well as deployment of resources (TISS 28 score, p = 0.709) did not differ between groups. No statistic significant difference between MOFA and control group regarding inflammation, impairment of coagulation, length of hospital stay or incidence of postoperative surgical complications were observed. Conclusions The MOFA concept did not result in an improvement of intestine function or faster recovery after elective colon or liver surgery compared to standard ERAS therapy. Omega-3 fatty acids showed no impairment of coagulation or improved resolution of inflammation. Further trials in a larger patient collective are needed to investigate potential beneficial effects of omega-3 fatty acids in abdominal surgery. Trial registration This trial was prospectively registered at the European Union Clinical Trials Register (EuDraCT 2005–004814-33, date: 10-05-2005, https://www.clinicaltrialsregister.eu/ctr-search/search?query=2005-004814-33+). Electronic supplementary material The online version of this article (10.1186/s12871-019-0823-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher Uhlig
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Thomas Rössel
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Axel Denz
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany.,Department of General Surgery, University Hospital of Friedrich-Alexander-University, Erlangen, Germany
| | - Sven Seifert
- Department of Gastrointestinal, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany.,Department of Thorax, Vascular and Endovascular Surgery, Chemnitz Hospital, Chemnitz, Germany
| | - Thea Koch
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Axel Rüdiger Heller
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.,Department of Anaesthesiology and Surgical Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
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10
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Abstract
PURPOSE OF REVIEW Lipid emulsions are an integral part of parenteral nutrition. Enteral nutrition is the preferred route to feed critically ill patients and parenteral nutrition is used in case of contraindications or when enteral nutrition does not reach the nutritional goals. n-3 Lipids are included into some newer lipid emulsions including fish oil or may be added by a fish oil-based lipid emulsion to lipid emulsion without fish oil. This review focuses on recent clinical trials, metaanalyses, and guidelines of parenteral nutrition with n-3 lipids in critically ill patients. RECENT FINDINGS Two single-center studies report a mortality benefit of adding fish oil-based lipid emulsions to the parenteral nutrition. Metaanalyses performed without these two studies had demonstrated beneficial effects of n-3 lipids regarding infections, length of stay, and time of mechanical ventilation but not on mortality. However, all metaanalyses judged the database derived from the underlying studies as not sufficient for a firm recommendation. Consecutively, guidelines and expert groups issue very cautious recommendations for the use of n-3 lipids in parenteral nutrition. SUMMARY Beneficial effects of n-3 lipids in trials and metaanalyses became available; however, high-quality multicenter randomized controlled trials are needed before more endorsing recommendation will be available.
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Affiliation(s)
- Konstantin Mayer
- University of Giessen and Marburg Lung Center (UGMLC), University Hospital of Giessen and Marburg, Justus Liebig University, Giessen, Germany
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11
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Current Evidence for the Use of Smoflipid® Emulsion in Critical Care Patients for Parenteral Nutrition. Crit Care Res Pract 2018; 2018:6301293. [PMID: 30584476 PMCID: PMC6280253 DOI: 10.1155/2018/6301293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/12/2018] [Indexed: 12/14/2022] Open
Abstract
There are strong data showing that malnutrition is highly prevalent in intensive care unit patients (20–50% in the worldwide), presenting a negative accumulated body energy balance. This results in an increased mortality, infections, and hospital length stay with high costs associated with the total treatment. Parenteral nutrition is the first option when the patient's physical condition is not suitable for oral nutrient intake. It is composed essentially by lipids as an energy source, metabolic, and structural function. However, these patients also require a mixture of essential and nonessential fatty acids (SMOF emulsions) to supply not only energy needs but also restore immunological, anti-inflammatory, and proregenerative functions. A revision of the safety and efficacy of Smoflipid® in patients requiring long-term parenteral nutrition was discussed here. Although controversial data are available indicating the contraindications or effectiveness of its use, most of studies presented indicate favorable benefits associated with improved clinical outcomes. The reported roles of this supplementation include positive immunomodulatory and anti-inflammatory effects, positive impact in liver function, reduction of hospital stay, and nosocomial infections as additional contributions to its energetic role, which in many cases results in reduced total costs per patient. Finally, many authors propose that the use of Smoflipid® should become a gold standard of parenteral nutrition in intensive unit care patients and that the costs associated with this supplement should not be limiting for its use, not only to improve the clinical outcome but also to reduce the treatment costs.
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12
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Mundi MS, Martindale RG, Hurt RT. Emergence of Mixed-Oil Fat Emulsions for Use in Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2017; 41:3S-13S. [DOI: 10.1177/0148607117742595] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert G. Martindale
- Division of General and Gastrointestinal Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Ryan T. Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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13
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Calder PC, Adolph M, Deutz NE, Grau T, Innes JK, Klek S, Lev S, Mayer K, Michael-Titus AT, Pradelli L, Puder M, Vlaardingerbroek H, Singer P. Lipids in the intensive care unit: Recommendations from the ESPEN Expert Group. Clin Nutr 2017; 37:1-18. [PMID: 28935438 DOI: 10.1016/j.clnu.2017.08.032] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/25/2017] [Accepted: 08/31/2017] [Indexed: 12/11/2022]
Abstract
This article summarizes the presentations given at an ESPEN Workshop on "Lipids in the ICU" held in Tel Aviv, Israel in November 2014 and subsequent discussions and updates. Lipids are an important component of enteral and parenteral nutrition support and provide essential fatty acids, a concentrated source of calories and building blocks for cell membranes. Whilst linoleic acid-rich vegetable oil-based enteral and parenteral nutrition is still widely used, newer lipid components such as medium-chain triglycerides and olive oil are safe and well tolerated. Fish oil (FO)-enriched enteral and parenteral nutrition appears to be well tolerated and confers additional clinical benefits, particularly in surgical patients, due to its anti-inflammatory and immune-modulating effects. Whilst the evidence base is not conclusive, there appears to be a potential for FO-enriched nutrition, particularly administered peri-operatively, to reduce the rate of complications and intensive care unit (ICU) and hospital stay in surgical ICU patients. The evidence for FO-enriched nutrition in non-surgical ICU patients is less clear regarding its clinical benefits and additional, well-designed large-scale clinical trials need to be conducted in this area. The ESPEN Expert Group supports the use of olive oil and FO in nutrition support in surgical and non-surgical ICU patients but considers that further research is required to provide a more robust evidence base.
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Affiliation(s)
- Philip C Calder
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, United Kingdom; National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO16 6YD, United Kingdom.
| | - Michael Adolph
- Department of Anesthesiology and Intensive Care Medicine, Nutrition Support Team, University Clinic Tübingen, 72074 Tübingen, Germany
| | - Nicolaas E Deutz
- Center for Translational Research in Aging & Longevity, Department of Health and Kinesiology, Texas A&M University, College Station, TX 77843, USA
| | - Teodoro Grau
- Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Jacqueline K Innes
- Human Development and Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, United Kingdom
| | - Stanislaw Klek
- General and Oncology Surgery Unit, Intestinal Failure Center, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Shaul Lev
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Hasharon Hospital and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Konstantin Mayer
- Department of Internal Medicine, Med. Clinik II, University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Adina T Michael-Titus
- Centre for Neuroscience and Trauma, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, United Kingdom
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, 10121 Turin, Italy
| | - Mark Puder
- Vascular Biology Program and the Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
| | - Hester Vlaardingerbroek
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Hasharon Hospital and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Feng Y, Li C, Zhang T, Pradelli L. Parenteral nutrition including an omega-3 fatty-acid-containing lipid emulsion for intensive care patients in China: a pharmacoeconomic analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:547-555. [PMID: 28919794 PMCID: PMC5592958 DOI: 10.2147/ceor.s139902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background/objectives Parenteral nutrition (PN) incorporating omega-3 fatty-acid-enriched lipid emulsions has been shown to be cost effective in Western populations. A pharmacoeconomic evaluation was performed within the Chinese intensive care unit (ICU) setting. This assessed whether the additional acquisition cost of PN with omega-3 fatty-acid-enriched lipid emulsion (SMOFlipid) vs standard PN was offset by improved clinical outcomes that can reduce subsequent costs. Materials and methods A pharmacoeconomic discrete event simulation model was developed, based on an update to efficacy data from a previous international meta-analysis, with China-specific clinical and economic input parameters. Sensitivity analyses were undertaken to assess the effects of uncertainty around input parameters. Results The model predicted that PN with an omega-3 fatty-acid-enriched lipid emulsion was more effective and less costly than PN with standard lipid emulsions for Chinese ICU patients, as follows: reduced length of overall hospital length of stay (19.48 vs 21.35 days, respectively), reduced length of ICU stay (5.03 vs 6.18 days, respectively), and prevention of 35.6% of nosocomial infections leading to a lower total cost per patient (¥47 189 [US $6937] vs ¥54 783 [US $8053], respectively). Additional treatment costs were offset by savings in overall hospital and ICU stay cost, and antibiotic cost, resulting in a mean cost saving of ¥7594 (US $1116) per patient. Sensitivity analyses confirmed the robustness of these findings. Conclusions PN enriched with an omega-3 fatty-acid-containing lipid emulsion vs standard PN may be effective in reducing length of hospital and ICU stay and infectious complications in Chinese ICU patients, and also decreases overall treatment costs. This results in a favorable cost-effectiveness ratio. Thus, PN enriched with an omega-3 fatty-acid-containing lipid emulsion can be seen as a win–win situation for patients, hospital administration, and health insurance companies.
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Affiliation(s)
- Yufei Feng
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Chao Li
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Tian Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, Piazza Carlo Emanuele II, Torino, Italy
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15
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Omega-3 Polyunsaturated Fatty Acids in Critical Illness: Anti-Inflammatory, Proresolving, or Both? OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:5987082. [PMID: 28694914 PMCID: PMC5488236 DOI: 10.1155/2017/5987082] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/25/2017] [Indexed: 12/14/2022]
Abstract
Prognosis and outcomes of critically ill patients are strictly related with inflammatory status. Inflammation involves a multitude of interactions between different cell types and chemical mediators. Omega-3 polyunsaturated fatty acids (PUFAs), mainly represented by eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are able to inhibit different pathways including leukocyte chemotaxis, adhesion molecule expression and interactions, and production of inflammatory cytokines, through the action of specialized proresolving mediators (SPMs). SPMs from omega-6 fatty acids, such as lipoxins, and from omega-3 fatty acids such as resolvins, protectins, and maresins, act in reducing/resolving the inflammatory process in critical diseases, stimulating the phases of resolution of inflammation. In this light, the resolution of inflammation is nowadays considered as an active process, instead of a passive process. In critical illness, SPMs regulate the excessive posttrauma inflammatory response, protecting organs from damage. This review focuses on the role of omega-3 PUFAs as pharma nutrition agents in acute inflammatory conditions, highlighting their effects as anti-inflammatory or proresolving agents.
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16
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Stark KD, Van Elswyk ME, Higgins MR, Weatherford CA, Salem N. Global survey of the omega-3 fatty acids, docosahexaenoic acid and eicosapentaenoic acid in the blood stream of healthy adults. Prog Lipid Res 2016; 63:132-52. [PMID: 27216485 DOI: 10.1016/j.plipres.2016.05.001] [Citation(s) in RCA: 340] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 05/14/2016] [Accepted: 05/18/2016] [Indexed: 02/05/2023]
Abstract
Studies reporting blood levels of the omega-3 polyunsaturated fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), were systematically identified in order to create a global map identifying countries and regions with different blood levels. Included studies were those of healthy adults, published in 1980 or later. A total of 298 studies met all inclusion criteria. Studies reported fatty acids in various blood fractions including plasma total lipids (33%), plasma phospholipid (32%), erythrocytes (32%) and whole blood (3.0%). Fatty acid data from each blood fraction were converted to relative weight percentages (wt.%) and then assigned to one of four discrete ranges (high, moderate, low, very low) corresponding to wt.% EPA+DHA in erythrocyte equivalents. Regions with high EPA+DHA blood levels (>8%) included the Sea of Japan, Scandinavia, and areas with indigenous populations or populations not fully adapted to Westernized food habits. Very low blood levels (≤4%) were observed in North America, Central and South America, Europe, the Middle East, Southeast Asia, and Africa. The present review reveals considerable variability in blood levels of EPA+DHA and the very low to low range of blood EPA+DHA for most of the world may increase global risk for chronic disease.
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Affiliation(s)
- Ken D Stark
- University of Waterloo, Department of Kinesiology, 200 University Avenue, Waterloo, ON, N2L 3G1, Canada.
| | - Mary E Van Elswyk
- Scientific Affairs, Van Elswyk Consulting, Inc., 10350 Macedonia St., Longmont, CO 80503, USA.
| | - M Roberta Higgins
- MEDetect Clinical Information Associates, Inc., PO Box 152, Skippack, PA 19474, USA.
| | | | - Norman Salem
- DSM Nutritional Products Ltd., 6480 Dobbin Road, Columbia, MD 21045, USA.
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17
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Klek S. Omega-3 Fatty Acids in Modern Parenteral Nutrition: A Review of the Current Evidence. J Clin Med 2016; 5:E34. [PMID: 26959070 PMCID: PMC4810105 DOI: 10.3390/jcm5030034] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/10/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022] Open
Abstract
Intravenous lipid emulsions are an essential component of parenteral nutrition regimens. Originally employed as an efficient non-glucose energy source to reduce the adverse effects of high glucose intake and provide essential fatty acids, lipid emulsions have assumed a larger therapeutic role due to research demonstrating the effects of omega-3 and omega-6 polyunsaturated fatty acids (PUFA) on key metabolic functions, including inflammatory and immune response, coagulation, and cell signaling. Indeed, emerging evidence suggests that the effects of omega-3 PUFA on inflammation and immune response result in meaningful therapeutic benefits in surgical, cancer, and critically ill patients as well as patients requiring long-term parenteral nutrition. The present review provides an overview of the mechanisms of action through which omega-3 and omega-6 PUFA modulate the immune-inflammatory response and summarizes the current body of evidence regarding the clinical and pharmacoeconomic benefits of intravenous n-3 fatty acid-containing lipid emulsions in patients requiring parenteral nutrition.
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Affiliation(s)
- Stanislaw Klek
- Stanley Dudrick's Memorial Hospital, General Surgery Unit, Skawina 32-050, Poland.
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18
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Wu GH, Gao J, Ji CY, Pradelli L, Xi QL, Zhuang QL. Cost and effectiveness of omega-3 fatty acid supplementation in Chinese ICU patients receiving parenteral nutrition. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:369-75. [PMID: 26170701 PMCID: PMC4492652 DOI: 10.2147/ceor.s81277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and objectives Clinical evidence supports the use of omega-3 polyunsaturated fatty acid (PUFA)-enriched lipid emulsions in place of standard lipid emulsions in parenteral nutrition (PN) for intensive care unit (ICU) patients, but uptake may be limited by higher costs. We compared clinical and economic outcomes for these two types of lipid emulsion in the Chinese ICU setting. Methods We developed a pharmacoeconomic discrete event simulation model, based on efficacy data from an international meta-analysis and patient characteristics, resource consumption, and unit costs from a Chinese institutional setting. Probabilistic sensitivity analyses were undertaken to assess the effects of uncertainty around input parameters. Model predictive validity was assessed by comparing results with data observed in a patient subset not used in the modeling. Results The model predicted that omega-3 PUFA-enriched emulsion (Omegaven® 10% fish oil emulsion) would dominate standard lipid emulsions, with better clinical outcomes and lower overall health care costs (mean savings ~10,000 RMB), mainly as a result of faster recovery and shorter hospital stay (by ~6.5 days). The external validation process confirmed the reliability of the model predictions. Conclusion Omega-3 PUFA-enriched lipid emulsions improved clinical outcome and decreased overall costs in Chinese ICU patients requiring PN.
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Affiliation(s)
- Guo Hao Wu
- Department of General Surgery, Fudan University, Shanghai, People's Republic of China
| | - Jian Gao
- Department of Nutrition, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Chun Yan Ji
- Department of Nutrition, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Lorenzo Pradelli
- AdRes Health Economics and Outcomes Research, Piazza Carlo Emanuele II, Torino, Italy
| | - Qiu Lei Xi
- Department of General Surgery, Fudan University, Shanghai, People's Republic of China
| | - Qiu Lin Zhuang
- Department of General Surgery, Fudan University, Shanghai, People's Republic of China
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