"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

Effectiveness and safety of early postpyloric feeding during therapeutic hypothermia in patients with large hemispheric infarction: A retrospective cohort study

BACKGROUND

What kind of feeding should be provided during therapeutic hypothermia (TH) in patients with large hemispheric infarction (LHI) is not clear. Therefore, we conducted a retrospective observational study to determine whether providing early postpyloric feeding (PPF) (<24 h after admission) is beneficial or harmful for patients with this condition.

METHODS

This study retrospectively screened 78 patients with LHI who were treated with TH from one neurological intensive care unit (ICU). The patients were receiving either early PPF (n = 52) or early parenteral nutrition (PN) (n = 26). Data regarding 30-day mortality, neurological outcome, nutrition-related laboratory indicators, ICU hospitalization time, mechanical ventilation (MV) duration, and complications were collected.

RESULTS

A greater number of patients who received early PPF had favorable neurologic outcome than those who received early PN (57.7% vs 30.7%, P = 0.025). The early PPF group had a lower severity of pulmonary infection than the early PN group, as measured by the Clinical Pulmonary Infection Score (7.33 ± 0.96 vs 9.42 ± 2.11, P = 0.006). The total protein and hemoglobin levels in the early PPF group were higher than those in the early PN group (59.56 ± 5.09 vs 56.52 ± 7.94 g/L, P = 0.046; 131.06 ± 19.58 vs 122.07 ± 17.72 g/L, P = 0.045). The MV duration and ICU hospitalization time were shorter in the early PPF group (13 [9;21] vs 21 [14;30] days, P = 0.006; 28 [22;36] vs 34 [33;51] days, P = 0.014). There were no significant differences in the incidence of catheter-related bloodstream infections, 30-day mortality, or nutrition intolerance between the two groups.

CONCLUSION

Early PPF is an effective and safe enteral nutrition method for patients with LHI receiving TH.

Outcomes associated with delayed enteral feeding after cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation and targeted temperature management

INTRODUCTION

While early enteral nutrition is generally preferred in critically ill patients, the optimal timing of feeding among refractory cardiac arrest patients is unknown. We examined the association between timing of enteral nutrition and patient survival and safety outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) who were treated with extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

We performed a retrospective analysis of 142 consecutive patients presenting with OHCA due to ventricular fibrillation or ventricular tachycardia treated with ECPR and targeted temperature management (TTM). Neurologically favorable survival and clinical outcomes were compared between patients who received early enteral nutrition (<48 h after admission to the intensive care unit) and patients receiving delayed enteral nutrition (initiated >48 h after admission).

RESULTS

Enteral nutrition was initiated in 90/142 (63%) patients. Early enteral nutrition was provided in 34/90 (38%) while delayed nutrition occurred in 56/90 (62%). In adjusted analysis including patients who received nutrition, delayed enteral feeding was associated with increased odds of neurologically favorable survival (29 vs 54%, CI 1.04-7.25, p = 0.04). There were no significant differences in the incidence of pneumonia (18 vs 27%, p = 0.16), gastrointestinal bleeding (5.9 vs 3.6%, p = 0.42), intestinal ischemia (5.9 vs 5.4%, p = 0.90), ileus (12 vs 11%, p = 0.98), or need for tracheostomy (15 vs 20%, p = 0.81) between early and late feeding groups.

CONCLUSION

In patients with refractory OHCA treated with ECPR and TTM, delayed enteral nutrition was associated with improved neurologically favorable survival. Adverse events related to enteral feeding were not associated with timing of feeding initiation.

Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury

The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.

Mild Hypothermia Pretreatment Attenuates Liver Ischemia Reperfusion Injury Through Inhibiting c-Jun NH2-terminal Kinase Phosphorylation in Rats

BACKGROUND

Mild hypothermia is known to be protected against ischemia reperfusion (IR) injury. But the exact mechanisms of protection have not yet been fully understood and its usage has been limited. Mild hypothermia pretreatment (MHP) is used to investigate the mechanisms of the protective effects against liver IR injury.

METHODS

Anesthetized male Sprague-Dawley rats were randomly divided into five groups including the normal group (N), sham group (S), MHP group, normothermia pretreatment (NP) + IR group, and the MHP + IR group. In the pretreatment groups, mild hypothermia (32.2 ± 0.3°C) and normothermia (37 ± 0.5°C) pretreatment were applied for 2 hours, respectively. Then the IR groups suffered partial (70%) hepatic ischemia for 1 hour and reperfusion for 6 hours. At last, hepatic injury, apoptosis, and protein expression were assessed.

RESULTS

Levels of serum alanine transaminase, hepatic injury, hepatocyte apoptosis, and c-Jun N-terminal kinase (JNK) phosphorylation were significantly higher in the IR groups. But when compared to NP, all these changes induced by IR were markedly attenuated by MHP. Serum alanine transaminase levels were 383.4 ± 13.1U/L in the MHP + IR group and 951.3 ± 39.4 U/L in the NP + IR group. The histologic score of liver injury in the MHP + IR group was 4.83 ± 1.17, whereas in the NP + IR group it was 10.5 ± 1.05. The proportion of apoptotic cells in the MHP + IR group was 11.58 ± 0.60, but in the NP + IR group, it was 44.95 ± 1.61. The phosphorylation of JNK was also significantly reduced in the MHP + IR group. All these differences are statistically significant (P < .05).

CONCLUSIONS

MHP could markedly reduce liver IR injury, and these protective effects may be mainly exerted via inhibition of JNK phosphorylation.