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Berger MM, De Waele E, Gramlich L, Jin J, Pantet O, Pichard C, Roffe AJ, Russell L, Singer P, Wischmeyer PE. How to interpret and apply the results of indirect calorimetry studies: A case-based tutorial. Clin Nutr ESPEN 2024; 63:856-869. [PMID: 39098603 DOI: 10.1016/j.clnesp.2024.07.1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/24/2024] [Accepted: 07/28/2024] [Indexed: 08/06/2024]
Abstract
Evidence is growing that the individual adjustment of energy targets guided by indirect calorimetry (IC) can improve outcome. With the development of a new generation of devices that are easier to use and rapid, it appears important to share knowledge and expertise that may be used to individualize nutrition care. Despite the focus of this tutorial being on one contemporary device, the principles of IC apply across existing devices and can assist tailoring the nutrition prescription and in assessing response to nutrition therapy. The present tutorial addresses its clinical application in intubated mechanically ventilated and spontaneously breathing adult patients (canopy), i.e. it covers the range from critical illness to outpatients. The cases that are presented show how the measured energy expenditure (mEE), and the respiratory quotient (RQ), i.e. the ratio of expired CO2 to consumed O2, should be applied in different cases, to adapt and individualize nutrition prescription, as it is a good marker of over- or underfeeding at the different stages of disease. The RQ also informs about the patient's body's capacity to use different substrates: the variations of RQ indicating the metabolic changes revealing insufficient or excessive feeding. The different cases reflect the use of a new generation device as a metabolic monitor that should be combined with other clinical observations and laboratory biomarkers. The tutorial also points to some shortcomings of the method, proposing alternatives.
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Affiliation(s)
- Mette M Berger
- Faculty of Biology & Medicine, Lausanne University, Lausanne, Switzerland.
| | - Elisabeth De Waele
- Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Leah Gramlich
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta Canada.
| | - Jennifer Jin
- Division of Gastroenterology, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, Canada.
| | - Olivier Pantet
- Department of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
| | - Claude Pichard
- Department of Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland.
| | - Ashlee Jean Roffe
- Nutrition Department, Endeavor Health Swedish Hospital, Chicago IL, USA.
| | - Lindsey Russell
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Pierre Singer
- Intensive Care Unit, Herzlia Medical Center and Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, and Intensive Care Unit, Herzlia Medical Center, Israel.
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA.
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Vargas MH, Chávez J, Del-Razo-Rodríguez R, Muñoz-Perea C, Romo-Domínguez KJ, Báez-Saldaña R, Rumbo-Nava U, Guerrero-Zúñiga S. Glycine by enteral route does not improve major clinical outcomes in severe COVID-19: a randomized clinical pilot trial. Sci Rep 2024; 14:11566. [PMID: 38773199 PMCID: PMC11109244 DOI: 10.1038/s41598-024-62321-7] [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: 07/28/2023] [Accepted: 05/15/2024] [Indexed: 05/23/2024] Open
Abstract
There is a worrying scarcity of drug options for patients with severe COVID-19. Glycine possesses anti-inflammatory, cytoprotective, endothelium-protective, and platelet-antiaggregant properties, so its use in these patients seems promising. In this open label, controlled clinical trial, inpatients with severe COVID-19 requiring mechanical ventilation randomly received usual care (control group) or usual care plus 0.5 g/kg/day glycine by the enteral route (experimental group). Major outcomes included mortality, time to weaning from mechanical ventilation, total time on mechanical ventilation, and time from study recruitment to death. Secondary outcomes included laboratory tests and serum cytokines. Patients from experimental (n = 33) and control groups (n = 23) did not differ in basal characteristics. There were no differences in mortality (glycine group, 63.6% vs control group, 52.2%, p = 0.60) nor in any other major outcome. Glycine intake was associated with lower fibrinogen levels, either evaluated per week of follow-up (p < 0.05 at weeks 1, 2, and 4) or as weighted mean during the whole hospitalization (608.7 ± 17.7 mg/dl vs control 712.2 ± 25.0 mg/dl, p = 0.001), but did not modify any other laboratory test or cytokine concentration. In summary, in severe COVID-19 glycine was unable to modify major clinical outcomes, serum cytokines or most laboratory tests, but was associated with lower serum fibrinogen concentration.Registration: ClinicalTrials.gov NCT04443673, 23/06/2020.
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Affiliation(s)
- Mario H Vargas
- Departamento de Investigación en Hiperreactividad Bronquial, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Calzada de Tlalpan 4502, CP 14080, Ciudad de México, México.
| | - Jaime Chávez
- Departamento de Investigación en Hiperreactividad Bronquial, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Calzada de Tlalpan 4502, CP 14080, Ciudad de México, México
| | - Rosangela Del-Razo-Rodríguez
- Servicio Clínico de Neumología Pediátrica, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
| | - Carolina Muñoz-Perea
- Servicio de Urgencias, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
| | - Karina Julieta Romo-Domínguez
- Servicio de Urgencias, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
- Servicio de Neumología, Hospital Infantil del Estado de Sonora, Hermosillo, Sonora, México
| | - Renata Báez-Saldaña
- Servicio Clínico 3, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
| | - Uriel Rumbo-Nava
- Servicio Clínico 3, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
| | - Selene Guerrero-Zúñiga
- Unidad de Medicina del Sueño, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México
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Kasotakis G, Whitmore C. Fat malabsorption in critical illness. Nutr Clin Pract 2024; 39 Suppl 1:S29-S34. [PMID: 38429961 DOI: 10.1002/ncp.11121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/21/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Malnutrition in critical illness is common and is associated with significant increases in adverse outcomes. A hypermetabolic state and underfeeding both contribute to the incidence of malnutrition. Malabsorption caused by critical illness is also an important contributor to the development of malnutrition. The early provision of enteral nutrition is associated with improved outcomes. Strategies for nutrition therapy must be informed by the alterations in absorption of macronutrients present in these patients. The following review examines alterations in fat metabolism during critical illness, and its consequences to overall nutrition status. Critical illness, as well as the sequalae of common medical interventions, may lead to alterations in the mechanical and chemical processes by which fat is digested and absorbed. Mechanical alterations include delayed gastric emptying and changes to the normal gut transit time. Pharmacologic interventions aimed at reducing these impacts may themselves, negatively affect efficient fat absorption. Exocrine pancreatic insufficiency can also occur in critical illness and may be underappreciated as a cause of fat malabsorption. Dysfunction of the gut lymphatics has been proposed as a contributing factor to fat malabsorption, and additional work is needed to better describe and quantify those effects. Achieving optimal outcomes for nutrition therapy requires recognition of these alterations in fat digestion.
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Affiliation(s)
- George Kasotakis
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Healthcare System, University of Virginia, Falls Church, Virginia, USA
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van Gassel RJ, Weijzen ME, Kouw IW, Senden JM, Wodzig WK, Olde Damink SW, van de Poll MC, van Loon LJ. Administration of Free Amino Acids Improves Exogenous Amino Acid Availability when Compared with Intact Protein in Critically Ill Patients: A Randomized Controlled Study. J Nutr 2024; 154:554-564. [PMID: 38103646 DOI: 10.1016/j.tjnut.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/24/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Protein digestion and amino acid absorption appear compromised in critical illness. The provision of enteral feeds with free amino acids rather than intact protein may improve postprandial amino acid availability. OBJECTIVE Our objective was to quantify the uptake of diet-derived phenylalanine after the enteral administration of intact protein compared with an equivalent amount of free amino acids in critically ill patients. METHODS Sixteen patients who were mechanically ventilated in intensive care unit (ICU) at risk of malabsorption received a primed continuous infusion of L-[ring-2H5]-phenylalanine and L-[ring-3,5-2H2]-tyrosine after an overnight fast. Patients were randomly allocated to receive 20 g intrinsically L-[1-13C]-phenylalanine-labeled milk protein or an equivalent amount of amino acids labeled with free L-[1-13C]-phenylalanine via a nasogastric tube over a 2-h period. Protein digestion and amino acid absorption kinetics and whole-body protein net balance were assessed throughout a 6-h period. RESULTS After enteral nutrient infusion, both plasma phenylalanine and leucine concentrations increased (P-time < 0.001), with a more rapid and greater rise after free amino acid compared with intact protein administration (P-time × treatment = 0.003). Diet-derived phenylalanine released into the circulation was 25% greater after free amino acids compared with intact protein administration [68.7% (confidence interval {CI}: 62.3, 75.1%) compared with 43.8% (CI: 32.4, 55.2%), respectively; P < 0.001]. Whole-body protein net balance became positive after nutrient administration (P-time < 0.001) and tended to be more positive after free amino acid in provision (P-time × treatment = 0.07). CONCLUSIONS The administration of free amino acids as opposed to intact protein further increases postprandial plasma amino acid availability in critically ill patients, allowing more diet-derived phenylalanine to become available to peripheral tissues. This trial was registered at clinicaltrials.gov as NCT04791774.
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Affiliation(s)
- Rob Jj van Gassel
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of Intensive Care Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands.
| | - Michelle Eg Weijzen
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Imre Wk Kouw
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Joan Mg Senden
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Will Khw Wodzig
- Central Diagnostic Laboratory, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Steven Wm Olde Damink
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of General, Visceral- and Transplantation Surgery, RWTH Aachen University, Aachen, Germany
| | - Marcel Cg van de Poll
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of Intensive Care Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Luc Jc van Loon
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
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Yamamoto R, Yamazaki H, Yamamoto S, Ueta Y, Ueno R, Yamamoto Y. Dose-response relationship between diarrhea quantity and mortality in critical care patients: A retrospective cohort study. PLoS One 2023; 18:e0280806. [PMID: 36780452 PMCID: PMC9925000 DOI: 10.1371/journal.pone.0280806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Previous studies have shown that diarrhea, defined as a dichotomized cutoff, is associated with increased mortality of patients in intensive care units (ICUs). This study aimed to examine the dose-response relationship between the quantity of diarrhea and mortality in ICU patients with newly developed diarrhea. METHODS We conducted this single-center retrospective cohort study. We consecutively included all adult patients with newly developed diarrhea in the ICU between January 2017 and December 2018. Newly developed diarrhea was defined according to the World Health Organization definition. The consistency of diarrhea was evaluated by the Bristol stool chart scale, and the quantity of diarrhea was assessed on the day when patients newly developed diarrhea. The primary outcome was in-hospital mortality. The risk ratio (RR) and 95% confidence interval (CI) for the association between diarrhea quantity and mortality were estimated using multivariable modified Poisson regression models. RESULTS Among the 231 participants, 68.4% were men; the median age was 72 years. The median diarrhea quantity was 401g (interquartile range [IQR] 230‒645g), and in-hospital mortality was 22.9%. More diarrhea at baseline was associated with higher in-hospital mortality; the adjusted RR (95% CI) per 200-g increase was 1.10 (1.01‒1.20), p = 0.029. In sensitivity analyses with near quartile categories of diarrhea quantity (<250g, 250-399g, 400-649g, ≥650g), the adjusted RRs for each respective category were 1.00 (reference), 1.02 (0.51-2.04), 1.29 (0.69-2.43), and 1.77 (0.99-3.21), p for trend = 0.033. CONCLUSIONS A greater quantity of diarrhea was an independent risk factor for in-hospital mortality. The diarrhea quantity may be an indicator of disease severity in ICU patients.
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Affiliation(s)
- Ryohei Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Shogoin-kawaramachi, Sakyo-ku, Kyoto, Japan
| | - Shungo Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto, Japan
| | - Yuna Ueta
- Department of Nutrition Management, Kameda Medical Center, Kamogawa, Japan
| | - Ryo Ueno
- The Australian and New Zealand Intensive Care Research Centre, Melbourne, VIC, Australia
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto, Japan
- * E-mail:
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6
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Lakenman P, van Schie J, van der Hoven B, Baart S, Eveleens R, van Bommel J, Olieman J, Joosten K. Nutritional intake and gastro-intestinal symptoms in critically ill COVID-19 patients. Clin Nutr 2022; 41:2903-2909. [PMID: 35504769 PMCID: PMC8986274 DOI: 10.1016/j.clnu.2022.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Critically ill COVID-19 patients seem hypermetabolic and difficult to feed enterally, due to gastro-intestinal (GI) symptoms such as high gastric residual volumes (GRV) and diarrhea. Our aim was to describe the association of nutritional intake and GI symptoms during first 14 days of ICU admission. METHODS Observational study including critically ill adult COVID-19 patients. Data on nutritional intake [enteral nutrition (EN) or parenteral nutrition] and GI symptoms were collected during 14 days after ICU admission. Target energy and protein feeding goals were calculated conform ESPEN guidelines. GI symptoms included GRV (ml/d), vomiting, abdominal distension, and faeces (ml/d). High GRV's were classified as ≥2 times ≥150 ml/d and diarrhea as Bristol stool chart ≥6. GI symptoms were defined as mild if at least one symptom occurred and as moderate when ≥2 symptoms occurred. Acute gastrointestinal injury (AGI) grades of III were classified as GI dysfunction and grades of IV were considered as GI failure with severe impact on distant organs. Linear mixed model analysis was performed to explore the development of nutritional intake and GI symptoms over time at day (D) 0, 4, 10, and 14. RESULTS One hundred and fifty patients were included [75% male; median age 64 years (IQR 54-70)]. BMI upon admission was 28 kg/m2 (IQR 25-33), of which 43% obese (BMI > 30 kg/m2). Most patients received EN during admission (98% D4; 96% D10-14). Mean energy goals increased from 87% at D4 to 93% D10-14 and protein goals (g/kg) were increasingly achieved during admission (84% D4; 93% D10-14). Presence of moderate GI symptoms decreased (10% D0; 6% D4-10; 5% D14), reversely mild GI symptoms increased. Occurrence of GI dysfunction fluctuated (1% D0; 18% D4; 12% D10; 8% D14) and none of patients developed grade IV GI failure. Development of high GRV fluctuated (5% D0; 23% D4; 14% D10; 8% D14) and occurrence of diarrhea slightly increased during admission (5% D0; 22% D4; 25% D10; 27% D14). Linear mixed models showed only an association between AGI grades III and lower protein intake at day 10 (p = 0.020). CONCLUSION Occurrence of GI symptoms was limited and seems no major barrier for EN in our group of critically COVID-19 patients. Nutritional intake was just below requirements during the first 14 days of ICU admission. The effect on nutritional status remains to be studied.
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Affiliation(s)
- P.L.M. Lakenman
- Division of Dietetics, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands,Corresponding author. Erasmus Medical Centre, Dr. M olewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - J.C. van Schie
- Division of Dietetics, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - B. van der Hoven
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - S.J. Baart
- Department of Biostatistics and Epidemiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - R.D. Eveleens
- Department of Anaesthesiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - J. van Bommel
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J.F. Olieman
- Division of Dietetics, Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - K.F.M. Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
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Jenkins B, Calder PC, Marino LV. A scoping review considering potential biomarkers or functional measures of gastrointestinal dysfunction and enteral feeding intolerance in critically ill adults. Clin Nutr ESPEN 2022; 52:331-339. [PMID: 36513473 DOI: 10.1016/j.clnesp.2022.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND & AIM Enteral feeding intolerance (EFI) as a result of gastrointestinal (GI) dysfunction in critically ill adults can lead to suboptimal nutritional delivery, increasing the risk of hospital acquired malnutrition. There are no validated measures of EFI or consensus as to which measures could be used to define EFI. The aim of this scoping review is to explore the validity of biomarkers, physiological or functional measures of GI dysfunction and EFI in critically ill adults characterising their use in routine clinical practice to identify those with GI dysfunction to better guide nutritional support. METHODS Database searches were completed in Ovid MEDLINE, Embase, CINAHL and Web of Science using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The search was performed until June 2022. Articles were included if they reported original studies that identify potential biomarkers or functional measures of EFI in critically ill adults. A nine-stage process was completed to extract and complete data synthesis. RESULTS 139 unique articles were identified. Following review of titles and abstracts, 114 of these articles were excluded, three further articles were excluded after full text review and 22 articles met the inclusion criteria. A thematic analysis of the articles included identified three overarching themes of GI dysfunction: (1) Serum biomarkers, (2) Physiological markers, and (3) Functional markers. Within the category of serum biomarkers, a further three sub-categories were identified: (i) enterohormones, (ii) markers of enterocyte function, and iii) cytokines and neurotransmitters. Some associations were seen between EFI and heparin binding protein, intra-abdominal pressure, cholecystokinin and acetylcholine levels but no markers are currently suitable for daily clinical use. CONCLUSIONS Further larger studies are required to characterise the relationships between serum biomarkers, physiological and functional makers of GI dysfunction in critically ill adults. A robust definition of GI dysfunction should be included in any future research.
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Affiliation(s)
- Bethan Jenkins
- Department of Dietetics/SLT, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
| | - Philip C Calder
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Luise V Marino
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; Paediatric Intensive Care Unit, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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8
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Berger MM, Pichard C. When is parenteral nutrition indicated? JOURNAL OF INTENSIVE MEDICINE 2022; 2:22-28. [PMID: 36789227 PMCID: PMC9923955 DOI: 10.1016/j.jointm.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023]
Abstract
The indications and contraindications of parenteral nutrition (PN) are discussed in view of recent clinical findings. For decades, PN has been restricted to patients unable to tolerate enteral nutrition (EN) intake owing to the perceived risk of severe side-effects. The evolution of the PN substrate composition and delivery of nutrition via all-in-one bags has dramatically improved the application prospects of PN. Recent studies show similar complication rates of nutrition therapy administered through enteral and intravenous routes. Therefore, indications of PN have, based on evidence, extended beyond complete gastrointestinal (GI) failure to include conditions such as insufficient EN generating persistent negative energy balance and insufficient protein intakes, malabsorption, or specific needs that are impossible to cover with EN feeds.
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Affiliation(s)
- Mette M. Berger
- Adult Intensive Care, Lausanne University Hospital, Lausanne 1011, Switzerland,Corresponding author: Mette M. Berger, Adult Intensive Care, Lausanne University Hospital, Lausanne 1011, Switzerland. E-mail address: .
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Geneva 1203, Switzerland
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9
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Zhang MM, Chen LN, Qian JM. Gastrointestinal manifestations and possible mechanisms of COVID-19 in different periods. J Dig Dis 2021; 22:683-694. [PMID: 34738727 PMCID: PMC8652439 DOI: 10.1111/1751-2980.13065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022]
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has become a pandemic worldwide. Although COVID-19 mainly affects the respiratory system, gastrointestinal (GI) manifestations have been frequently reported in such cases, even as initial symptoms. There have been several studies on different GI manifestations in patients with mild and severe disease or in remission. In this review article we summarized different GI manifestations of COVID-19 at various disease stages and the possible mechanisms based on published literatures, as well as the significance of GI manifestations in systemic inflammatory injury.
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Affiliation(s)
- Meng Meng Zhang
- Department of GastroenterologyPeking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Lu Ni Chen
- Department of Microbiology and Tumor and Cell BiologyKarolinska InstituteSolnaSweden
| | - Jia Ming Qian
- Department of GastroenterologyPeking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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10
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Understanding the physiology of human defaecation and disorders of continence and evacuation. Nat Rev Gastroenterol Hepatol 2021; 18:751-769. [PMID: 34373626 DOI: 10.1038/s41575-021-00487-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.
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Gastrointestinal Tolerance and Protein Absorption Markers with a New Peptide Enteral Formula Compared to a Standard Intact Protein Enteral Formula in Critically Ill Patients. Nutrients 2021; 13:nu13072362. [PMID: 34371872 PMCID: PMC8308653 DOI: 10.3390/nu13072362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/04/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
The aim of this exploratory study was to investigate gastrointestinal tolerance and protein absorption markers with a new enteral peptide formula (PF) compared to an isocaloric enteral intact protein standard formula (SF) containing the same amount of protein in ICU patients. Patients admitted to a cardio-thoracic intensive care unit expected to receive tube feeding for ≥5 days were randomized to receive either PF (1.5 kcal/mL) or SF in a double-blind manner for ≤14 days. Twenty-six patients were randomized (13 SF and 13 PF) and 23 (12 SF and 11 PF) completed at least 5 days of product administration. There were no statistically significant differences between the feeds during the first 5 days of intervention for diarrhea (SF:3 (23%); PF:5 (39%), p = 0.388), vomiting (SF:1 (8%); PF:2 (15%), p = 0.549), constipation (SF:7 (54%), PF:3 (23%), p = 0.115), and high gastric residual volume (>500 mL: SF:1 (8%); PF: 2 (15%), p = 0.535). There were no differences in plasma amino acids or urinary markers of protein absorption and metabolism. In conclusion, no major differences were found in tolerability and protein absorption markers between the standard intact protein formula and the peptide formula.
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12
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Lakenman PLM, van der Hoven B, Schuijs JM, Eveleens RD, van Bommel J, Olieman JF, Joosten KFM. Energy expenditure and feeding practices and tolerance during the acute and late phase of critically ill COVID-19 patients. Clin Nutr ESPEN 2021; 43:383-389. [PMID: 34024544 PMCID: PMC8016730 DOI: 10.1016/j.clnesp.2021.03.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Different metabolic phases can be distinguished in critical illness, which influences nutritional treatment. Achieving optimal nutritional treatment during these phases in critically ill patients is challenging. COVID-19 patients seem particularly difficult to feed due to gastrointestinal problems. Our aim was to describe measured resting energy expenditure (mREE) and feeding practices and tolerance during the acute and late phases of critical illness in COVID-19 patients. METHODS Observational study including critically ill mechanically ventilated adult COVID-19 patients. Indirect calorimetry (Q-NRG+, Cosmed) was used to determine mREE during the acute (day 0-7) and late phase (>day 7) of critical illness. Data on nutritional intake, feeding tolerance and urinary nitrogen loss were collected simultaneously. A paired sample t-test was performed for mREE in both phases. RESULTS We enrolled 21 patients with a median age of 59 years [44-66], 67% male and median BMI of 31.5 kg/m2 [25.7-37.8]. Patients were predominantly fed with EN in both phases. No significant difference in mREE was observed between phases (p = 0.529). Sixty-five percent of the patients were hypermetabolic in both phases. Median delivery of energy as percentage of mREE was higher in the late phase (94%) compared to the acute phase (70%) (p = 0.001). Urinary nitrogen losses were significant higher in the late phase (p = 0.003). CONCLUSION In both the acute and late phase, the majority of the patients were hypermetabolic and fed enterally. In the acute phase patients were fed hypocaloric whereas in the late phase this was almost normocaloric, conform ESPEN guidelines. No significant difference in mREE was observed between phases. Hypermetabolism in both phases in conjunction with an increasing loss of urinary nitrogen may indicate that COVID-19 patients remain in a prolonged acute, catabolic phase.
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Affiliation(s)
- P L M Lakenman
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - B van der Hoven
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - J M Schuijs
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - R D Eveleens
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J van Bommel
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - J F Olieman
- Division of Dietetics, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - K F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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13
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Abstract
PURPOSE OF REVIEW Progress has been made in our understanding of gut dysfunction in critical illness. This review will outline new findings and give perspectives based on previous knowledge and concurrent advances in nutrition. RECENT FINDINGS The relationship between gut dysfunction and poor outcomes in critical illness has received considerable interest. It remains uncertain whether gut dysfunction is merely a marker of illness severity or if it is directly responsible for prolonged critical illness and increased mortality. This relationship is difficult to ascertain given there is no agreed method for identification and quantification; biomarkers such as intestinal fatty acid binding protein and citrulline show promise but require further study. Recent studies have investigated strategies to deliver enteral nutrition targets with impacts on gut function, including high calorie or protein formulae, intermittent regimes and novel prokinetics. SUMMARY Gut dysfunction is associated with poor outcomes, but it remains uncertain whether strategies to improve gut function will influence survival and recovery.
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Goelen N, Janssen P, Ripken D, van Horssen P, Byloos K, Ghysels S, Putzeys G, Hofman Z, Vandecaveye V, Tack J. Effect of protein composition of enteral formula on gastric content volume during continuous feeding: A randomized controlled cross-over study in healthy adults. Clin Nutr 2021; 40:2663-2672. [PMID: 33933732 DOI: 10.1016/j.clnu.2021.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/18/2021] [Accepted: 03/12/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Enteral nutrition with polymeric intact protein formula is the preferred medical nutrition strategy in critically ill patients when oral intake is insufficient. Enteral nutrition formulas are often rich in casein protein, which has coagulating properties. Coagulation in the stomach impedes gastric emptying and might result in high gastric residual volumes which are a clinical sign of gastrointestinal intolerance and a major reason to decrease or to discontinue enteral feeding. In this study the impact of protein composition of enteral formula on gastric content volume (GCV) during and after continuous feeding was tested in healthy volunteers in whom gastrointestinal conditions of critically ill patients were mimicked. METHODS An enteral formula including 4 proteins (P4) with non-coagulating properties was compared to a casein-dominant formula (Cas) with coagulating properties. Esomeprazole and codeine were administered to mimic stress ulcer prophylaxis and induce gastroduodenal motor dysfunction, both being hallmarks of critically ill patients. GCV was measured with magnetic resonance imaging during and after continuous enteral feeding (100 mL/h for 4h) in a randomized single-center cross-over study. Results are provided as mean (SD). Significance level of p < 0.05 was applied. RESULTS Twenty subjects completed the study (14 women, 6 men, 25.8 (4.6) years old, BMI: 22.5 (1.5) kg/m2). The GCV as change from baseline at T = 240 (primary endpoint) did not differ between study products (P4: 124.3 (83.4) vs. Cas: 137.1 (102.0) mL, 95% CI: -57.4, 27.0, p = 0.457). During feeding and after cessation of feeding, the area under the GCV-curve (AUC0-360 GCV) for P4 and Cas was 44631.1 (15546.1) and 52822.2 (19686.1) mL∗min, respectively (p = 0.061). During feeding the GCV was lower at T = 180 min (175.4 (64.8) vs. 205.2 (75.4) mL, p = 0.038) and after cessation of feeding at T = 300 min (81.3 (71.1) vs. 116.3 (84.3) mL, p = 0.004) and T = 330 min (39.9 (53.9) vs. 73.6 (81.1) mL, p = 0.031). With P4 it took less time to reach half of the GCV at T = 240 min compared to Cas (52.8 (27.6) vs. 65.4 (29.9) min, p = 0.020). CONCLUSIONS In this study in which healthy volunteers received esomeprazole and codeine to mimic gastrointestinal conditions of critically ill patients, observations of secondary endpoints suggest faster gastric emptying with P4 compared to Cas, and less gastric accumulation, possibly due to the non-coagulating properties of the P4 protein blend. Considering the small effect and the possible clinical relevance of reduced intragastric accumulation of enteral nutrition, the potential impact of protein coagulation should be further investigated in relevant study populations. Registered under Netherlands Trial Register identifier no. NTR6423.
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Affiliation(s)
- Nick Goelen
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Pieter Janssen
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Dina Ripken
- Danone Nutricia Research, Specialized Nutrition, Utrecht, the Netherlands
| | - Peter van Horssen
- Danone Nutricia Research, Specialized Nutrition, Utrecht, the Netherlands
| | - Kris Byloos
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Stefan Ghysels
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Guido Putzeys
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Zandrie Hofman
- Danone Nutricia Research, Specialized Nutrition, Utrecht, the Netherlands
| | | | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.
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Reintam Blaser A, Deane AM, Preiser J, Arabi YM, Jakob SM. Enteral Feeding Intolerance: Updates in Definitions and Pathophysiology. Nutr Clin Pract 2020; 36:40-49. [DOI: 10.1002/ncp.10599] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Annika Reintam Blaser
- Department of Intensive Care Medicine Lucerne Cantonal Hospital Lucerne Switzerland
- Department of Anaesthesiology and Intensive Care University of Tartu Tartu Estonia
| | - Adam M. Deane
- Department of Medicine and Radiology The University of Melbourne Melbourne Medical School Royal Melbourne Hospital Parkville Victoria Australia
| | | | - Yaseen M. Arabi
- College of Medicine King Saud bin Abdulaziz University for Health Sciences (KSAU‐HS) and King Abdullah International Medical Research Center Riyadh Saudi Arabia
| | - Stephan M. Jakob
- Department of Intensive Care Medicine University Hospital (Inselspital) Bern University of Bern Bern Switzerland
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16
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Diarrhea and elevation of plasma markers of cholestasis are common and often occur concomitantly in critically ill patients. J Crit Care 2020; 60:120-126. [PMID: 32799181 DOI: 10.1016/j.jcrc.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE We aimed to describe epidemiology of diarrhea and cholestasis in critically ill patients and explore associations between these two conditions. MATERIAL AND METHODS We performed a retrospective study including all consecutive patients who stayed in the ICU for at least 3 days and in whom plasma measurements of liver enzymes/cholestasis parameters were performed. Diarrhea was defined as 3 or more loose or liquid stools per day and cholestasis as increase of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) 1.5 times above the upper limit of normality. RESULTS Diarrhea was observed in 26.1% and cholestasis in 27.9% of study patients, about one third of the cases in both diarrhea and cholestasis occurred beyond the first week of patient's ICU stay. Cholestasis occurred in 45.6% of patients with diarrhea vs 28.0% of patients without diarrhea (p < 0.001). In 94 patients (13.1%) both diarrhea and cholestasis occurred, cholestasis was more commonly (2/3 of cases) documented before manifestation of diarrhea. CONCLUSIONS Cholestasis is more common in patients with diarrhea and vice versa. Diarrhea and cholestasis both occur in approximately one quarter of ICU patients, with significant proportion manifesting beyond the first week in the ICU.
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Measures of Dietary Fat and Energy Absorption in Healthy Adults. Pancreas 2020; 49:845-854. [PMID: 32590620 PMCID: PMC8335406 DOI: 10.1097/mpa.0000000000001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Existing reference ranges for stool fat and energy absorption were developed using subjects in controlled environments on precise diets. This study measured energy and fat absorption in healthy, community-dwelling adults eating a moderate-to-high fat American diet via stool- and serum-based methods. METHODS This was a secondary analysis of healthy subjects recruited as the comparison group in a chronic pancreatitis study. Subjects recorded dietary intake and collected stool over 3-day periods. Stool was analyzed for fat content using the coefficient of fat absorption and for energy content using bomb calorimetry. The malabsorption blood test (MBT) was used to measure dietary fat absorption. RESULTS Nineteen subjects had mean daily stool measures of 143 g wet weight, 4.1 g of fat, and 178 kcal. The mean coefficients of fat and energy absorption were 96% and 93%, respectively. The mean MBT area under the curve cut-point was greater than 8 mg·h/dL. CONCLUSIONS This study confirms the historical reference range for the coefficient of fat absorption in contemporary healthy, community-dwelling adults on a moderate-to-high fat diet. The study contributes to the development of reference range values for multiple bomb calorimetry-based outcomes of stool energy losses and to the serum-based MBT as a promising method for measuring fat absorption.
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Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study. Int J Nurs Stud 2020; 108:103605. [PMID: 32502821 DOI: 10.1016/j.ijnurstu.2020.103605] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/05/2020] [Accepted: 04/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients. OBJECTIVE The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively. DESIGN Retrospective cohort study. SETTING Cardiac-Surgery Intensive Care Unit of a University Hospital. PARTICIPANTS Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas. METHODS Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives). RESULTS In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding. CONCLUSIONS Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.
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Reintam Blaser A, Preiser JC, Fruhwald S, Wilmer A, Wernerman J, Benstoem C, Casaer MP, Starkopf J, van Zanten A, Rooyackers O, Jakob SM, Loudet CI, Bear DE, Elke G, Kott M, Lautenschläger I, Schäper J, Gunst J, Stoppe C, Nobile L, Fuhrmann V, Berger MM, Oudemans-van Straaten HM, Arabi YM, Deane AM. Gastrointestinal dysfunction in the critically ill: a systematic scoping review and research agenda proposed by the Section of Metabolism, Endocrinology and Nutrition of the European Society of Intensive Care Medicine. Crit Care 2020; 24:224. [PMID: 32414423 PMCID: PMC7226709 DOI: 10.1186/s13054-020-02889-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Gastrointestinal (GI) dysfunction is frequent in the critically ill but can be overlooked as a result of the lack of standardization of the diagnostic and therapeutic approaches. We aimed to develop a research agenda for GI dysfunction for future research. We systematically reviewed the current knowledge on a broad range of subtopics from a specific viewpoint of GI dysfunction, highlighting the remaining areas of uncertainty and suggesting future studies. METHODS This systematic scoping review and research agenda was conducted following successive steps: (1) identify clinically important subtopics within the field of GI function which warrant further research; (2) systematically review the literature for each subtopic using PubMed, CENTRAL and Cochrane Database of Systematic Reviews; (3) summarize evidence for each subtopic; (4) identify areas of uncertainty; (5) formulate and refine study proposals that address these subtopics; and (6) prioritize study proposals via sequential voting rounds. RESULTS Five major themes were identified: (1) monitoring, (2) associations between GI function and outcome, (3) GI function and nutrition, (4) management of GI dysfunction and (5) pathophysiological mechanisms. Searches on 17 subtopics were performed and evidence summarized. Several areas of uncertainty were identified, six of them needing consensus process. Study proposals ranked among the first ten included: prevention and management of diarrhoea; management of upper and lower feeding intolerance, including indications for post-pyloric feeding and opioid antagonists; acute gastrointestinal injury grading as a bedside tool; the role of intra-abdominal hypertension in the development and monitoring of GI dysfunction and in the development of non-occlusive mesenteric ischaemia; and the effect of proton pump inhibitors on the microbiome in critical illness. CONCLUSIONS Current evidence on GI dysfunction is scarce, partially due to the lack of precise definitions. The use of core sets of monitoring and outcomes are required to improve the consistency of future studies. We propose several areas for consensus process and outline future study projects.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sonja Fruhwald
- Department of Anaesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Wilmer
- Department of Medical Intensive Care, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan Wernerman
- Department of Anaesthesiology and Intensive Care Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
- Cardiovascular Critical Care & Anesthesia Research and Evaluation (3CARE), Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Michael P. Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
| | - Arthur van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Olav Rooyackers
- Department of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Cecilia I. Loudet
- Department of Intensive Care, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Danielle E. Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London, UK
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Kott
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ingmar Lautenschläger
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jörn Schäper
- Department of Anaesthesiology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Christian Stoppe
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Leda Nobile
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Medicine B, University of Münster, Münster, Germany
| | - Mette M. Berger
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Yaseen M. Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) and King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | - Adam M. Deane
- The University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria 3050 Australia
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20
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Ertl VM, Höring M, Schött HF, Blücher C, Kjølbæk L, Astrup A, Burkhardt R, Liebisch G. Quantification of diacylglycerol and triacylglycerol species in human fecal samples by flow injection Fourier transform mass spectrometry. Anal Bioanal Chem 2020; 412:2315-2326. [PMID: 32198533 PMCID: PMC7118049 DOI: 10.1007/s00216-020-02416-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
The intestinal microbiome plays an important role in human health and disease and fecal materials reflect the microbial activity. Thus, analysis of fecal metabolites provides insight in metabolic interactions between gut microbiota and host organism. In this work, we applied flow injection analysis coupled to Fourier transform mass spectrometry (FIA-FTMS) to identify and quantify lipid species in human fecal samples. Fecal homogenates were subjected to lipid extraction and analyzed by FIA-FTMS. The analysis of different subjects revealed a vast heterogeneity of lipid species abundance. The majority of samples displayed prominent signals of triacylglycerol (TG) and diacylglycerol (DG) species that could be verified by MS2 spectra. Therefore, we focused on the quantification of TG and DG. Method validation included limit of quantification, linearity, evaluation of matrix effects, recovery, and reproducibility. The validation experiments demonstrated the suitability of the method, with exception for approximately 10% of samples, where we observed coefficients of variation higher than 15%. Impaired reproducibility was related to sample inhomogeneity and could not be improved by additional sample preparation steps. Additionally, these experiments demonstrated that compared with aqueous samples, samples containing isopropanol showed higher amounts of DG, presumably due to lysis of bacteria and increased TG lipolysis. These effects were sample-specific and substantiate the high heterogeneity of fecal materials as well as the need for further evaluation of pre-analytic conditions. In summary, FIA-FTMS offers a fast and accurate tool to quantify DG and TG species and is suitable to provide insight into the fecal lipidome and its role in health and disease.
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Affiliation(s)
- Verena M Ertl
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Marcus Höring
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Hans-Frieder Schött
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Christina Blücher
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Louise Kjølbæk
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Nørre Allé 51, 2200, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Nørre Allé 51, 2200, Copenhagen, Denmark
| | - Ralph Burkhardt
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Gerhard Liebisch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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21
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Abstract
Acute intestinal failure (AIF), "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, requiring parenteral nutrition", is common, but very often neglected part of multiorgan dysfunction syndrome (MODS) in the critically ill patients. It is now increasingly being recognized as a cause of prolonged ICU and hospital stay and poor outcome. Multidisciplinary team approach, systematic approach to management with treatment of sepsis, early mobilization and enteral feeding with prokinetics if required, control of intra-abdominal pressure and surgical intervention, when mandated, can help treat AIF and improve patient outcomes. How to cite this article: Chandankhede SR, Kulkarni AP. Acute Intestinal Failure. Indian J Crit Care Med 2020;24(Suppl 4):S168-S174.
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Affiliation(s)
- Shweta R Chandankhede
- Department of Critical Care Medicine, Care Hospitals, Banjara Hills, Hyderabad, Telangana, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesiology, Critically Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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22
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Abstract
Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. In critically ill patients, EN must be discontinued or interrupted, if gastrointestinal complications, particularly vomiting and bowel movement disorders, do not resolve with appropriate management. To avoid such gastrointestinal complications, EN should be started as soon as possible with a small amount of EN first and gradually increased. EN itself may also promote intestinal peristalsis. The measures to decrease the risk of reflux and aspiration include elevation the head of the bed (30° to 45°), switch to continuous administration, administration of prokinetic drugs or narcotic antagonists to promote gastrointestinal motility, and switch to jejunal access (postpyloric route). Moreover, the control of bowel movement is also important for intensive care and management. In particular, prolonged diarrhea can cause deficiency in nutrient absorption, malnutrition, and increase in mortality. In addition, diarrhea may cause a decrease the circulating blood volume, metabolic acidosis, electrolyte abnormalities, and contamination of surgical wounds and pressure ulcers. If diarrhea occurs in critically ill patients on EN management, it is important to determine whether diarrhea is EN-related or not. After ruling out the other causes of diarrhea, the measures to prevent EN-related diarrhea include switch to continuous infusion, switch to gastric feeding, adjustment of agents that improve gastrointestinal peristalsis or laxative, administration of antidiarrheal drugs, changing the type of EN formula, and semisolidification of EN formula. One of the best ways to success for EN management is to continue as long as possible without interruption and discontinuation of EN easily by appropriate measures, even if gastrointestinal complications occur.
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Affiliation(s)
- Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, South 1 West 16, Chuo-ku, Sapporo, Hokkaido 060-8543 Japan
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Zhang G, Zhang K, Cui W, Hong Y, Zhang Z. The effect of enteral versus parenteral nutrition for critically ill patients: A systematic review and meta-analysis. J Clin Anesth 2018; 51:62-92. [PMID: 30098572 DOI: 10.1016/j.jclinane.2018.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/25/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE To analyze the effect of enteral nutrition compared with parenteral nutrition in critically ill patients. DESIGN Systematic review and meta-analysis of randomized controlled trials. SETTING Intensive care unit. PATIENTS 23 trials containing 6478 patients met our inclusion criteria. INTERVENTION A systematical literature search was conducted to identify eligible trials in electronic databases including PubMed, Embase, Scopus, EBSCO and Cochrane Library. The primary outcome was mortality, the secondary outcomes were gastrointestinal complications, bloodstream infections, organ failures, length of stay in ICU and hospital. We performed a predefined subgroup analyses to explore the treatment effect by mean age, publication date and disease types. MAIN RESULTS The result showed no significant effect on overall mortality rate (OR 0.98, 95%CI 0.81 to 1.18, P = 0.83, I2 = 19%) and organ failure rate (OR 0.87, 95%CI 0.75 to 1.01, P = 0.06, I2 = 16%). The use of EN had more beneficial effects with fewer bloodstream infections when compared to PN (OR 0.59, 95%CI 0.43 to 0.82, P = 0.001, I2 = 27%) and this was more noteworthy in the subgroup analysis for critical surgical patients (OR 0.36, 95%CI 0.22 to 0.59, P < 0.0001, I2 = 0%). EN was associated with reduction in hospital LOS (MD -0.90, 95%CI -1.63 to -0.17, P = 0.21, I2 = 0%) but had an increase incidence of gastrointestinal complications (OR 2.00, 95%CI 1.76 to 2.27, P < 0.00001, I2 = 0%). CONCLUSION For critically ill patients, the two routes of nutrition support had no different effect on mortality rate. The use of EN could decrease the incidence of bloodstream infections and reduce hospital LOS but was associated with increased risk of gastrointestinal complications.
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Affiliation(s)
- Gensheng Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Wei Cui
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
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Vieira LV, Pedrosa LAC, Souza VS, Paula CA, Rocha R. Incidence of diarrhea and associated risk factors in patients with traumatic brain injury and enteral nutrition. Metab Brain Dis 2018; 33:1755-1760. [PMID: 30014176 DOI: 10.1007/s11011-018-0287-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/10/2018] [Indexed: 02/05/2023]
Abstract
To determine the occurrence of diarrhea and associated factors in critically ill patients with traumatic brain injury (TBI) in use of nutritional therapy. Prospective cohort study conducted in an Intensive Care Unit (ICU) of a General Hospital reference in trauma. We evaluated TBI patients who stayed less than 72 h in the ICU, who were using EN for at least 48 h. Definition of diarrhea it was considered three or more episodes of liquid stools or semi-liquid at 24 h. For analysis were evaluated demographic, epidemiological, clinical and nutritional data. Twenty-three patients were evaluated, being 86.9% male, median 33 years old (IQR = 25-52 years) and 16-day ICU stay (IQR = 10-26 days). Diarrhea occurred in 69.6% of the patients and they had a longer time in the ICU (p = 0.007). All patients who used combination prokinetic therapy (metoclopramide and erythromycin) and used antibiotics for more than 8 days had diarrhea (p = 0.057 and p = 0.007, respectively). The incidence of diarrhea was high in TBI patients with enteral nutrition and was associated with the use of antibiotics for more than one week.
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Affiliation(s)
- Luiza Valois Vieira
- Departamento de Ciências da Nutrição, Escola de Nutrição, Universidade Federal da Bahia, Avenida Araújo Pinho, 32, Canela, CEP: 40.110-150, Salvador, Bahia, Brasil.
| | - Livia Alves Carvalho Pedrosa
- Departamento de Ciências da Nutrição, Escola de Nutrição, Universidade Federal da Bahia, Avenida Araújo Pinho, 32, Canela, CEP: 40.110-150, Salvador, Bahia, Brasil
| | - Viviane Sahade Souza
- Departamento de Ciências da Nutrição, Escola de Nutrição, Universidade Federal da Bahia, Avenida Araújo Pinho, 32, Canela, CEP: 40.110-150, Salvador, Bahia, Brasil
| | | | - Raquel Rocha
- Departamento de Ciências da Nutrição, Escola de Nutrição, Universidade Federal da Bahia, Avenida Araújo Pinho, 32, Canela, CEP: 40.110-150, Salvador, Bahia, Brasil
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Kuchnia AJ, Conlon B, Greenberg N. Natural Bioactive Food Components for Improving Enteral Tube Feeding Tolerance in Adult Patient Populations. Nutr Clin Pract 2018; 33:107-120. [PMID: 28820648 DOI: 10.1177/0884533617722164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
Tube feeding (TF) is the most common form of nutrition support. In recent years, TF administration has increased among patient populations within and outside hospital settings, in part due to greater insurance coverage, reduced use of parenteral nutrition, and improved formularies suitable for sole source nutrition. With increasing life expectancy and improved access to TFs, the number of adults dependent on enteral nutrition is expected to grow. However, enteral TF intolerance (ETFI) is the most common complication of TFs, typically presenting with at least 1 adverse gastrointestinal event, including nausea, diarrhea, and constipation. ETFI often leads to reductions in TF volume with associated energy and protein deficits. Potentially ensuing malnutrition is a major public health concern due its effects on increased risk of morbidity and mortality, infections, prolonged hospital length of stay, and higher healthcare costs. As such, there is a need for intervention strategies to prevent and reduce ETFI. Incorporating whole foods with bioactive properties is a promising strategy. Emerging research has elucidated bioactive properties of whole foods with specific benefits for the prevention and management of adverse gastrointestinal events commonly associated with TFs. However, lack of evidence-based recommendations and technological challenges have limited the use of such foods in commercial TF formulas. This review addresses research gaps by discussing 5 whole foods (rhubarb, banana, curcumin, peppermint oil, and ginger) with bioactive attributes identified through literature searches and clinical experience as having substantial scientific rationale to consider their application for ETFI in adult populations.
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Affiliation(s)
- Adam J Kuchnia
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Saint Paul, Minnesota, USA
| | - Beth Conlon
- Nestlé Nutrition R&D Centers Inc, Bridgewater, New Jersey, USA
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Reintam Blaser A, Berger MM. Early or Late Feeding after ICU Admission? Nutrients 2017; 9:E1278. [PMID: 29168739 PMCID: PMC5748729 DOI: 10.3390/nu9121278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/06/2017] [Accepted: 11/06/2017] [Indexed: 12/15/2022] Open
Abstract
The feeding of critically ill patients has recently become a controversial issue, as several studies have provided unexpected and contradictory results. Earlier beliefs regarding energy requirements in critical illness-especially during the initial phase-have been challenged. In the current review, we summarize existing evidence about fasting and the impact of early vs. late feeding on the sick organism's responses. The most important points are the non-nutritional advantages of using the intestine, and recognition that early endogenous energy production as an important player in the response must be integrated in the nutrient prescription. There is as of yet no bedside tool to monitor dynamics in metabolism and the magnitude of the endogenous energy production. Hence, an early "full-feeding strategy" exposes patients to involuntary overfeeding, due to the absence of an objective measure enabling the adjustment of the nutritional therapy. Suggestions for future research and clinical practice are proposed.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, 51014 Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland.
| | - Mette M Berger
- Service of Intensive Care and Burns, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland.
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27
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Gangadharan A, Choi SE, Hassan A, Ayoub NM, Durante G, Balwani S, Kim YH, Pecora A, Goy A, Suh KS. Protein calorie malnutrition, nutritional intervention and personalized cancer care. Oncotarget 2017; 8:24009-24030. [PMID: 28177923 PMCID: PMC5410360 DOI: 10.18632/oncotarget.15103] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/23/2017] [Indexed: 12/27/2022] Open
Abstract
Cancer patients often experience weight loss caused by protein calorie malnutrition (PCM) during the course of the disease or treatment. PCM is expressed as severe if the patient has two or more of the following characteristics: obvious significant muscle wasting, loss of subcutaneous fat; nutritional intake of <50% of recommended intake for 2 weeks or more; bedridden or otherwise significantly reduced functional capacity; weight loss of >2% in 1 week, 5% in 1 month, or 7.5% in 3 months. Cancer anorexia-cachexia syndrome (CACS) is a multifactorial condition of advanced PCM associated with underlying illness (in this case cancer) and is characterized by loss of muscle with or without loss of fat mass. Cachexia is defined as weight loss of more than 5% of body weight in 12 months or less in the presence of chronic disease. Hence with a chronic illness on board even a small amount of weight loss can open the door to cachexia. These nutritional challenges can lead to severe morbidity and mortality in cancer patients. In the clinic, the application of personalized medicine and the ability to withstand the toxic effects of anti-cancer therapies can be optimized when the patient is in nutritional homeostasis and is free of anorexia and cachexia. Routine assessment of nutritional status and appropriate intervention are essential components of the effort to alleviate effects of malnutrition on quality of life and survival of patients.
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Affiliation(s)
- Anju Gangadharan
- The Genomics and Biomarkers Program, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Sung Eun Choi
- Department of Family, Nutrition, and Exercise Sciences, Queens College, The City University of New York, Flushing, NY, USA
| | - Ahmed Hassan
- The Genomics and Biomarkers Program, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Nehad M Ayoub
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Gina Durante
- Department of Clinical Nutrition, Baystate Medical Center, Springfield, MA, USA
| | - Sakshi Balwani
- The Genomics and Biomarkers Program, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Young Hee Kim
- Department of Clinical Nutrition, Baystate Medical Center, Springfield, MA, USA
| | - Andrew Pecora
- Clinical Divisions, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Andre Goy
- Clinical Divisions, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
| | - K Stephen Suh
- The Genomics and Biomarkers Program, JT Cancer Center, Hackensack University Medical Center, Hackensack Meridian Health, Hackensack, NJ, USA
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Effect of the route of nutrition and L-alanyl-L-glutamine supplementation in amino acids' concentration in trauma patients. Eur J Trauma Emerg Surg 2017; 44:869-876. [PMID: 28980034 DOI: 10.1007/s00068-017-0851-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/25/2017] [Indexed: 12/26/2022]
Abstract
PURPOSE Our purpose was to assess the amino acids' (AAs) profile in trauma patients and to assess the effect of the route of nutrition and the exogenous ALA-GLN dipeptide supplementation on plasma AAs' concentration. METHODS This is a secondary analysis of a previous randomized controlled trial. On day 1 and day 6 after trauma, plasma concentration of 25 AAs was measured using reverse phase high-performance liquid chromatography. Results were analyzed in relation to the route of nutrition and supplementation of ALA-GLN dipeptide. Differences between plasma AAs' concentrations at day 1 and day 6 were evaluated using the Student's t test or Mann-Whitney-Wilcoxon test. One-way ANOVA and the Kruskal-Wallis test were used to compare groups. A two-sided p value less than 0.05 was considered statistically significant. RESULTS Ninety-eight patients were analyzed. Mean plasma concentrations at day 1 were close to the lower normal level for most AAs. At day 6 we found an increase in the eight essential AAs' concentrations and in 9 out of 17 measured non-essential AAs. At day 6 we found no differences in plasma concentrations for the sum of all AAs (p = .72), glutamine (p = .31) and arginine (p = .23) distributed by the route of nutrition. Administration of ALA-GLN dipeptide increased the plasma concentration of alanine (p = .004), glutamine (p < .001) and citrulline (p = .006). CONCLUSIONS We found an early depletion of plasma AAs' concentration which partially recovered at day 6, which was unaffected by the route of nutrition. ALA-GLN dipeptide supplementation produced a small increase in plasma levels of glutamine and citrulline.
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Fushimi N, Yamada M, Hachiya H, Ito S, Shibuya T, Ohashi N, Mori A. Effects of two different glutamine-containing enteral supplements on stool frequency and density in elderly patients recovering from acute critical illness. Geriatr Gerontol Int 2017; 17:2514-2519. [PMID: 28675566 DOI: 10.1111/ggi.13121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 04/25/2017] [Accepted: 05/11/2017] [Indexed: 11/28/2022]
Abstract
AIM Glutamine has various beneficial functions in the gastrointestinal tract. The present study was designed to investigate the effect of two different glutamine supplements on bowel movement at the start of enteral feeding in elderly inpatients. METHODS This was a double-blind, prospective, randomized comparison study. A total of 25 patients aged >75 years recovering from a critical illness in a non-intensive care unit and scheduled for tube feeding were recruited. Of them, 22 consenting patients were randomly assigned to two groups: glutamine-fiber-oligosaccharide treatment group (n = 11) and glutamine F treatment group (n = 11). They were given glutamine three times daily at a dosage of 9 g/day. Enteral nutrition was given at the same dosage to both groups for the duration of the study. The end-points were stool frequency, Bristol Scale Form Score, bowel function index (Bristol Scale Form Score × stool frequency), the percentage of patients with stool frequency over three per day and those with a BSFS of 6 or 7 in each group. RESULTS There were no significant differences between the two groups in terms of patient characteristics before the study. All the end-points in the glutamine F group were significantly lower than those in the glutamine-fiber-oligosaccharide group. CONCLUSIONS Compared with glutamine-fiber-oligosaccharide, glutamine F administration resulted in stool hardening and reduced stool frequency in elderly inpatients recovering from acute critical illness in non-intensive care units. The effects might be caused by the different additive components of glutamine supplements. Geriatr Gerontol Int 2017; 17: 2514-2519.
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Affiliation(s)
- Nobutoshi Fushimi
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Munenori Yamada
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Hiroki Hachiya
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Shun Ito
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Takashi Shibuya
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Noritsugu Ohashi
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
| | - Akihiro Mori
- Department of Endocrinology and Diabetes, Ichinomiyanishi Hospital, Aichi, Japan
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30
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Peters JH, Wierdsma NJ, Beishuizen A, Teerlink T, van Bodegraven AA. Intravenous citrulline generation test to assess intestinal function in intensive care unit patients. Clin Exp Gastroenterol 2017; 10:75-81. [PMID: 28496350 PMCID: PMC5417678 DOI: 10.2147/ceg.s121100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Assessment of a quantifiable small intestinal function test is cumbersome. Fasting citrulline concentrations have been proposed as a measure of enterocyte function and elaborated into a citrulline generation test (CGT), which is applicable only when glutamine is administered orally. CGT is an oral test, limiting its use, for example, in critically ill patients. Objective Assessment of normative values and feasibility of an intravenously performed CGT in intensive care unit (ICU) patients with presumed gastrointestinal motility disturbances, especially when performed intravenously. Design CGT reference values were determined in 16 stable ICU patients using two different CGT methods, namely following either enteral or intravenous glutamine administration and both with simultaneous arterial and venous plasma citrulline sampling at six time-points. Plasma amino acid analysis was performed using reverse-phase high-performance liquid chromatography. Results The median total generation of citrulline in 90 min (CGT iAUCT90) was markedly higher with arterial citrulline sampling compared with venous citrulline sampling, being 724±585 and 556±418 µmol/L/min for enteral glutamine, respectively (p=0.02) and 977±283 and 769±231 µmol/L/min for intravenous glutamine, respectively (p=0.0004). The median slope (time-dependent increase) for plasma arterial and venous citrulline during the CGT was 0.20±0.16 and 0.18±0.12 µmol/L/min for enteral glutamine, respectively (p=0.004) and 0.22±0.16 and 0.19±0.05 µmol/L/min for intravenous glutamine, respectively (p=0.02). Conclusion Intravenous glutamine administration combined with arterial plasma citrulline sampling yielded the least variation in CGT characteristics in stable ICU patients. A 2-point measurement test had comparable test characteristics as a 6-point measurement CGT and seems promising.
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Affiliation(s)
- Job Hc Peters
- Department of Gastroenterology and Hepatology, Red Cross Hospital, Beverwijk
| | - Nicolette J Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Small Bowel Disease Unit, VU University Medical Center, Amsterdam
| | - Albertus Beishuizen
- Department of Intensive Care, VU University Medical Center, Amsterdam.,Department of Intensive Care, Intensive Care Center, Medisch Spectrum Twente, Enschede
| | - Tom Teerlink
- Department of Clinical Chemistry, Metabolic Laboratory, VU University Medical Center, Amsterdam
| | - Ad A van Bodegraven
- Department of Gastroenterology, Small Bowel Disease Unit, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Geriatrics, Intensive Care and Internal Medicin (Co-MIK), Zuyderland MC, Heerlen-Sittard-Geleen, the Netherlands
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Afolabi OOD, Sohail M. Microwaving human faecal sludge as a viable sanitation technology option for treatment and value recovery - A critical review. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2017; 187:401-415. [PMID: 27836558 DOI: 10.1016/j.jenvman.2016.10.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/12/2016] [Accepted: 10/15/2016] [Indexed: 05/15/2023]
Abstract
The prolonged challenges and terrible consequences of poor sanitation, especially in developing economies, call for the exploration of new sustainable sanitation technologies. Such technologies must be: capable of effectively treating human faecal wastes without any health or environmental impacts; scalable to address rapid increases in population and urbanization; capable of meeting environmental regulations and standards for faecal management; and competitive with existing strategies. Further and importantly, despite its noxiousness and pathogenic load, the chemical composition of human faecal sludge indicates that it could be considered a potentially valuable, nutrient-rich renewable resource, rather than a problematic waste product. New approaches to faecal sludge management must consequently seek to incorporate a 'valuable resource recovery' approach, compatible with stringent treatment requirements. This review intends to advance the understanding of human faecal sludge as a sustainable organic-rich resource that is typically high in moisture (up to 97 per cent), making it a suitable candidate for dielectric heating, i.e. microwave irradiation, to promote faecal treatment, while also recovering value-added products such as ammonia liquor concentrate (suitable for fertilizers) and chars (suitable for fuel) - which can provide an economic base to sustain the technology. Additionally, microwaving human faecal sludge represents a thermally effective approach that can destroy pathogens, eradicate the foul odour associated human faecal sludge, while also preventing hazardous product formations and/or emissions, aside from other benefits such as improved dewaterability and heavy metals recovery. Key technological parameters crucial for scaling the technology as a complementary solution to the challenges of onsite sanitation are also discussed.
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Affiliation(s)
- Oluwasola O D Afolabi
- School of Civil and Building Engineering, Loughborough University Loughborough, LE11 3TU, UK.
| | - M Sohail
- School of Civil and Building Engineering, Loughborough University Loughborough, LE11 3TU, UK
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Abstract
PURPOSE OF REVIEW The current review summarizes different aspects of assessment of gastrointestinal function and provides a practical approach to management of adult patients with gastrointestinal dysfunction in the ICU. RECENT FINDINGS Different ways to define gastrointestinal failure have been used in the past. Recently, the term 'acute gastrointestinal injury (AGI)' has been proposed to specifically describe gastrointestinal dysfunction as a part of multiple organ dysfunction syndrome. Possible pathophysiological mechanisms and different aspects in assessment of gastrointestinal function in adult ICU patients are presented. Currently, there is no single marker that could reliably describe gastrointestinal dysfunction. Therefore, monitoring and management is still based on complex assessment of different gastrointestinal symptoms and feeding intolerance, even though this approach includes a large amount of subjectivity. The possible role of biomarkers (citrulline, enterohormones, etc.) and additional parameters like intra-abdominal pressure remains to be clarified. SUMMARY Defining gastrointestinal failure remains challenging but broad consensus needs to be reached and disseminated soon to allow conduct of interventional studies. A systematic approach to management of gastrointestinal problems is recommended.
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de Brito-Ashurst I, Preiser JC. Diarrhea in Critically Ill Patients: The Role of Enteral Feeding. JPEN J Parenter Enteral Nutr 2016; 40:913-23. [PMID: 27271709 DOI: 10.1177/0148607116651758] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/26/2016] [Indexed: 12/20/2022]
Abstract
This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.
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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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Ali Abdelhamid Y, Cousins CE, Sim JA, Bellon MS, Nguyen NQ, Horowitz M, Chapman MJ, Deane AM. Effect of Critical Illness on Triglyceride Absorption. JPEN J Parenter Enteral Nutr 2015; 39:966-72. [PMID: 24963026 DOI: 10.1177/0148607114540214] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/24/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Adequate nutrition support for critically ill patients optimizes outcome, and enteral feeding is the preferred route of nutrition. Small intestinal glucose absorption is frequently impaired in critical illness. Despite lipid being a major constituent of liquid nutrient administered, there is little information about lipid absorption during critical illness. OBJECTIVES To determine small intestinal lipid, as well as glucose, absorption in critical illness compared with health. MATERIALS AND METHODS Twenty-nine mechanically ventilated critically ill patients and 16 healthy volunteers were studied. Liquid nutrient (60 mL, 1 kcal/mL), containing 200 µL (13)C-triolein and 3 g 3-O-methyl-glucose (3-OMG), was infused directly into the duodenum at a rate of 2 kcal/min. Exhaled (13)CO2 and serum 3-OMG concentrations were measured at timed intervals over 360 minutes. Lipid absorption was measured as the cumulative percentage dose (cPDR) of (13)CO2 recovered at 360 minutes. Glucose absorption was measured as the area under the 3-OMG concentration curve. Data are median (range) and analyzed using the Mann-Whitney U and Pearson correlation tests. RESULTS Lipid absorption was markedly less in the critically ill (cPDR(13)CO2: patients, 22.6% [0%-100%] vs healthy participants, 40.7% [5.3%-84.7%]; P = .018). While glucose absorption was less at 60 minutes in the critically ill (3-OMG60: 13.2 [3.5-29.5] vs 21.1 [9.3-31.9] mmol/L·min; P = .003), this was not apparent at 360 minutes (3-OMG360: 92.7 [54.5-147.9] vs 107.9 [64.0-168.7] mmol/L·min; P = .126). There was no relationship between lipid and glucose absorption. CONCLUSION Small intestinal absorption of lipid is diminished during critical illness.
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Affiliation(s)
| | - Caroline E Cousins
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Jennifer A Sim
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Max S Bellon
- Department of Nuclear Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - Nam Q Nguyen
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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Rose C, Parker A, Jefferson B, Cartmell E. The Characterization of Feces and Urine: A Review of the Literature to Inform Advanced Treatment Technology. CRITICAL REVIEWS IN ENVIRONMENTAL SCIENCE AND TECHNOLOGY 2015; 45:1827-1879. [PMID: 26246784 PMCID: PMC4500995 DOI: 10.1080/10643389.2014.1000761] [Citation(s) in RCA: 564] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
The safe disposal of human excreta is of paramount importance for the health and welfare of populations living in low income countries as well as the prevention of pollution to the surrounding environment. On-site sanitation (OSS) systems are the most numerous means of treating excreta in low income countries, these facilities aim at treating human waste at source and can provide a hygienic and affordable method of waste disposal. However, current OSS systems need improvement and require further research and development. Development of OSS facilities that treat excreta at, or close to, its source require knowledge of the waste stream entering the system. Data regarding the generation rate and the chemical and physical composition of fresh feces and urine was collected from the medical literature as well as the treatability sector. The data were summarized and statistical analysis was used to quantify the major factors that were a significant cause of variability. The impact of this data on biological processes, thermal processes, physical separators, and chemical processes was then assessed. Results showed that the median fecal wet mass production was 128 g/cap/day, with a median dry mass of 29 g/cap/day. Fecal output in healthy individuals was 1.20 defecations per 24 hr period and the main factor affecting fecal mass was the fiber intake of the population. Fecal wet mass values were increased by a factor of 2 in low income countries (high fiber intakes) in comparison to values found in high income countries (low fiber intakes). Feces had a median pH of 6.64 and were composed of 74.6% water. Bacterial biomass is the major component (25-54% of dry solids) of the organic fraction of the feces. Undigested carbohydrate, fiber, protein, and fat comprise the remainder and the amounts depend on diet and diarrhea prevalence in the population. The inorganic component of the feces is primarily undigested dietary elements that also depend on dietary supply. Median urine generation rates were 1.42 L/cap/day with a dry solids content of 59 g/cap/day. Variation in the volume and composition of urine is caused by differences in physical exertion, environmental conditions, as well as water, salt, and high protein intakes. Urine has a pH 6.2 and contains the largest fractions of nitrogen, phosphorus, and potassium released from the body. The urinary excretion of nitrogen was significant (10.98 g/cap/day) with urea the most predominant constituent making up over 50% of total organic solids. The dietary intake of food and fluid is the major cause of variation in both the fecal and urine composition and these variables should always be considered if the generation rate, physical, and chemical composition of feces and urine is to be accurately predicted.
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Affiliation(s)
- C. Rose
- Cranfield Water Science Institute, Cranfield University, Cranfield, Bedfordshire, United Kingdom
| | - A. Parker
- Cranfield Water Science Institute, Cranfield University, Cranfield, Bedfordshire, United Kingdom
| | - B. Jefferson
- Cranfield Water Science Institute, Cranfield University, Cranfield, Bedfordshire, United Kingdom
| | - E. Cartmell
- Cranfield Water Science Institute, Cranfield University, Cranfield, Bedfordshire, United Kingdom
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Casaer MP, Ziegler TR. Nutritional support in critical illness and recovery. Lancet Diabetes Endocrinol 2015; 3:734-45. [PMID: 26071886 DOI: 10.1016/s2213-8587(15)00222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.
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Affiliation(s)
- Michael P Casaer
- Intensive Care Department and Laboratory of Intensive Care Medicine, Leuven University Hospitals, Leuven, Belgium.
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.
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Affiliation(s)
| | - Rebecca Fritzshall
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin
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Shirai K, Yoshida S, Matsumaru N, Toyoda I, Ogura S. Effect of enteral diet enriched with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with sepsis-induced acute respiratory distress syndrome. J Intensive Care 2015; 3:24. [PMID: 26015869 PMCID: PMC4443653 DOI: 10.1186/s40560-015-0087-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 04/17/2015] [Indexed: 12/26/2022] Open
Abstract
Background In this study, the effects of an enteral diet enriched with eicosapentaenoic acid (EPA), γ-linolenic acid (GLA), and antioxidants were compared with a standard enteral diet in critically ill patients with sepsis-induced acute respiratory distress syndrome (ARDS). Methods This study was a single-center, prospective, randomized, single-blind, controlled trial in our Advanced Critical Care Center. Patients were randomized to receive a continuous EPA, GLA, and antioxidant-enriched diet (study group), or an isocaloric standard diet (control group). Results Twenty-three of 46 patients were in the study group, and the other 23 were in the control group. Duration of mechanical ventilation, incidence of new nosocomial infections, changes over time in Sequential Organ Failure Assessment (SOFA) scores, and 60-day mortality were not significantly different between the two groups. The ratio of partial pressure of oxygen to fraction of inspired oxygen on day 7 was significantly higher in the study group (233.0 [185.5–282.8] vs. 274.0 [225.5–310.8], p = 0.021). Duration of ICU stay was significantly shorter in the study group than in the control group (24.0 [20.0–30.0] vs. 15.0 [11.0–24.0], p = 0.008). Conclusions An enteral diet enriched with EPA, GLA, and antioxidants did not improve duration of mechanical ventilation, SOFA score, incidence of new nosocomial infections, or mortality but did favorably influence duration of ICU stay in critically ill patients with sepsis-induced ARDS. Electronic supplementary material The online version of this article (doi:10.1186/s40560-015-0087-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kunihiro Shirai
- Department of Emergency and Critical Care Medicine Ichinomiya Municipal Hospital, Bunkyo, Ichinomiya, Aichi 491-8558 Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naoki Matsumaru
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Izumi Toyoda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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Chapman MJ, Deane AM. Gastrointestinal dysfunction relating to the provision of nutrition in the critically ill. Curr Opin Clin Nutr Metab Care 2015; 18:207-12. [PMID: 25603226 DOI: 10.1097/mco.0000000000000149] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW During critical illness, enteral nutrition remains central to clinical care and an understanding of gut dysfunction is therefore important. Contemporary data have contributed to our knowledge in this area and this review will concentrate on recently published studies. RECENT FINDINGS It is difficult to precisely measure gastric emptying and nutrient absorption as part of routine clinical care. However, techniques for the measurement of these parameters for research purposes have been refined, studied and validated. These methodologies allow the evaluation of novel treatments that modulate gastric emptying. Quantification and an understanding of the mechanisms of nutrient malabsorption may facilitate the development of therapeutic agents to improve absorption and/or formulae, which are more readily absorbed, thereby improving nutritional and clinical outcomes. SUMMARY Improved understanding of gut pathophysiology in critical illness provides opportunities for the development and testing of novel and targeted treatment strategies, with the objective to improve clinical outcomes in this group.
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Affiliation(s)
- Marianne J Chapman
- aDepartment of Critical Care Services, Royal Adelaide Hospital, North Terrace bNHMRC Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health cDiscipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
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McNally JD, Iliriani K, Pojsupap S, Sampson M, O'Hearn K, McIntyre L, Fergusson D, Menon K. Rapid normalization of vitamin D levels: a meta-analysis. Pediatrics 2015; 135:e152-66. [PMID: 25511115 DOI: 10.1542/peds.2014-1703] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Vitamin D deficiency may represent a modifiable risk factor to improve outcome in severe illness. The efficacy of high-dose regimens in rapid normalization of vitamin D levels is uncertain. METHODS We conducted a systematic review of pediatric clinical trials administering high-dose vitamin D to evaluate 25-hydroxyvitamin D (25[OH]D) response and characteristics associated with final 25(OH)D levels by using Medline, Embase, and the Cochrane Central Register of Controlled Trials, including reference lists of systematic reviews and eligible publications. Uncontrolled and controlled trials reporting 25(OH)D levels after high-dose (≥1000 IU) ergocalciferol or cholecalciferol were selected. Two reviewers independently extracted and verified predefined data fields. RESULTS We identified 88 eligible full-text articles. Two of 6 studies that administered daily doses approximating the Institute of Medicine's Tolerable Upper Intake Level (1000-4000 IU) to vitamin D-deficient populations achieved group 25(OH)D levels >75 nmol/L within 1 month. Nine of 10 studies evaluating loading therapy (>50 000 IU) achieved group 25(OH)D levels >75 nmol/L. In meta-regression, baseline 25(OH)D, regimen type, dose, age, and time factors were associated with final 25(OH)D levels. Adverse event analysis identified increased hypercalcemia risk with doses >400 000 IU, but no increased hypercalcemia or hypercalciuria with loading doses <400 000 IU (or 10 000 IU/kg). Few studies in adolescents evaluated loading dose regimens >300 000 IU. CONCLUSIONS Rapid normalization of vitamin D levels is best achieved by using loading therapy that considers disease status, baseline 25(OH)D, and age (or weight). Loading doses >300 000 IU should be avoided until trials are conducted to better evaluate risk and benefit.
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Affiliation(s)
- J Dayre McNally
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada;
| | - Klevis Iliriani
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; School of Medicine, Trinity College, Dublin, Ireland
| | - Supichaya Pojsupap
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Division of Critical Care, Department of Pediatrics, Phramonghutklao Hospital, Bangkok, Thailand; and
| | - Margaret Sampson
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Katie O'Hearn
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Dean Fergusson
- Department of Epidemiology and Community Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kusum Menon
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Weijs PJM, Cynober L, DeLegge M, Kreymann G, Wernerman J, Wolfe RR. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:591. [PMID: 25565377 PMCID: PMC4520087 DOI: 10.1186/s13054-014-0591-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Proteins and amino acids are widely considered to be subcomponents in nutritional support. However, proteins and amino acids are fundamental to recovery and survival, not only for their ability to preserve active tissue (protein) mass but also for a variety of other functions. Understanding the optimal amount of protein intake during nutritional support is therefore fundamental to appropriate clinical care. Although the body adapts in some ways to starvation, metabolic stress in patients causes increased protein turnover and loss of lean body mass. In this review, we present the growing scientific evidence showing the importance of protein and amino acid provision in nutritional support and their impact on preservation of muscle mass and patient outcomes. Studies identifying optimal dosing for proteins and amino acids are not currently available. We discuss the challenges physicians face in administering the optimal amount of protein and amino acids. We present protein-related nutrition concepts, including adaptation to starvation and stress, anabolic resistance, and potential adverse effects of amino acid provision. We describe the methods for assessment of protein status, and outcomes related to protein nutritional support for critically ill patients. The identification of a protein target for individual critically ill patients is crucial for outcomes, particularly for specific subpopulations, such as obese and older patients. Additional research is urgently needed to address these issues.
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Affiliation(s)
- Peter J M Weijs
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Intensive Care Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Nutrition and Dietetics, Amsterdam University of Applied Sciences, Wibautstraat 2-4 1091 GM, Amsterdam, the Netherlands. .,EMGO+ Institute of Health and Care Research, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Luc Cynober
- Clinical Chemistry Department, Cochin and Hôtel-Dieu Hospitals, APHP, 1 place du Parvis Notre-Dame 75004, Paris, France. .,Nutrition Lab, EA 4466, Department of Experimental, Metabolic and Clinical Biology, Faculty of Pharmacy, Paris Descartes University, 12 rue de l'Ecole de Médicine 75270, Paris, France.
| | - Mark DeLegge
- Baxter Healthcare, Deerfield, IL, 60015-4625, USA.
| | - Georg Kreymann
- Baxter Healthcare SA Europe, CH-8010, Zürich, Switzerland.
| | - Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 86, Stockholm, Sweden.
| | - Robert R Wolfe
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, 4243 Ireland St #336, College Station, TX, 77843, USA.
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Deane AM, Rayner CK, Keeshan A, Cvijanovic N, Marino Z, Nguyen NQ, Chia B, Summers MJ, Sim JA, van Beek T, Chapman MJ, Horowitz M, Young RL. The effects of critical illness on intestinal glucose sensing, transporters, and absorption. Crit Care Med 2014; 42:57-65. [PMID: 23963126 DOI: 10.1097/ccm.0b013e318298a8af] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Providing effective enteral nutrition is important during critical illness. In health, glucose is absorbed from the small intestine via sodium-dependent glucose transporter-1 and glucose transporter-2, which may both be regulated by intestinal sweet taste receptors. We evaluated the effect of critical illness on glucose absorption and expression of intestinal sodium-dependent glucose transporter-1, glucose transporter-2, and sweet taste receptors in humans and mice. DESIGN Prospective observational study in humans and mice. SETTING ICU and university-affiliated research laboratory. SUBJECTS Human subjects were 12 critically ill patients and 12 healthy controls. In the laboratory 16-week-old mice were studied. INTERVENTIONS Human subjects underwent endoscopy. Glucose (30 g) and 3-O-methylglucose (3 g), used to estimate glucose absorption, were infused intraduodenally over 30 minutes. Duodenal mucosa was biopsied before and after infusion. Mice were randomized to cecal ligation and puncture to model critical illness (n = 16) or sham laparotomy (control) (n = 8). At day 5, mice received glucose (100 mg) and 3-O-methylglucose (10 mg) infused intraduodenally prior to mucosal tissue collection. MEASUREMENTS AND MAIN RESULTS Quantitative polymerase chain reaction was performed to measure absolute (human) and relative levels of sodium-dependent glucose transporter-1, glucose transporter-2, and taste receptor type 1 member 2 (T1R2) transcripts. Blood samples were assayed for 3-O-methylglucose to estimate glucose absorption. Glucose absorption was three-fold lower in critically ill humans than in controls (p = 0.002) and reduced by a similar proportion in cecal ligation and puncture mice (p = 0.004). In critically ill patients, duodenal levels of sodium-dependent glucose transporter-1, glucose transporter-2, and T1R2 transcript were reduced 49% (p < 0.001), 50% (p = 0.009), and 85% (p = 0.007), whereas in the jejunum of cecal ligation and puncture mice sodium-dependent glucose transporter-1, glucose transporter-2, and T1R2 transcripts were reduced by 55% (p < 0.001), 50% (p = 0.002), and 69% (p = 0.004). CONCLUSIONS Critical illness is characterized by markedly diminished glucose absorption, associated with reduced intestinal expression of glucose transporters (sodium-dependent glucose transporter-1 and glucose transporter-2) and sweet taste receptor transcripts. These changes are paralleled in cecal ligation and puncture mice.
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Affiliation(s)
- Adam M Deane
- 1Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia. 2Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia. 3Discipline of Medicine, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia. 4Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia. 5Discipline of Medicine, Nerve-Gut Research Laboratory, Level-1 Hanson Institute, Adelaide, South Australia, Australia
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Wierdsma NJ, Peters JHC, van Bokhorst-de van der Schueren MAE, Mulder CJJ, Metgod I, van Bodegraven AA. Bomb calorimetry, the gold standard for assessment of intestinal absorption capacity: normative values in healthy ambulant adults. J Hum Nutr Diet 2013; 27 Suppl 2:57-64. [PMID: 23647171 DOI: 10.1111/jhn.12113] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intestinal absorption capacity is considered to be the best method for assessing overall digestive intestinal function. Earlier reference values for intestinal function in healthy Dutch adults were based on a study that was conducted in an inpatient metabolic unit setting in a relatively small series. The present study aimed to readdress and describe the intestinal absorption capacity of healthy adults, who were consuming their usual (Western European) food and beverage diet, in a standard ambulatory setting. METHODS Twenty-three healthy subjects (aged 22-60 years) were included in the analyses. Nutritional intake (energy and macronutrients) was determined with a 4-day nutritional diary. Subsequently, mean faecal losses of energy (by bomb calorimetry), fat, protein and carbohydrate were determined following a 3-day faecal collection. Finally, intestinal absorption capacity was calculated from the differences between intake and losses. RESULTS Mean (SD) daily faeces production was 141 (49) g (29% dry weight), containing 891 (276) kJ [10.7 (1.3) kJ g(-1) wet faeces; 22.6 (2.5) kJ g(-1) dry faeces], 5.2 (2.2) g fat, 10.0 (3.8) g protein and 29.7 (11.7) g carbohydrates. Mean (SD) intestinal absorption capacity of healthy subjects was 89.4% (3.8%) for energy, 92.5% (3.7%) for fat, 86.9% (6.4%) for protein and 87.3% (6.6%) for carbohydrates. CONCLUSIONS The present study provides normative values for both stool nutrient composition and intestinal energy and macronutrient absorption in healthy adults on a regular Dutch diet in an ambulatory setting. Intestinal energy absorption was found to be approximately 90%.
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Affiliation(s)
- N J Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Centre, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Gastrointestinal dysmotility and dysfunction underlie our difficulties in providing adequate nutrition by the enteral route to our critically ill patients. RECENT FINDINGS Recent studies have quantified gastric emptying and nutrient absorption. Slow gastric emptying is common and probably mediated by cholecystokinin and reduced active ghrelin concentrations. The cause of impaired nutrient absorption is not yet fully understood but may be related to small intestinal blood flow and/or mucosal factors. The absorption of the different macronutrients may be affected in different ways both by critical illness and by therapies. A better understanding of this may optimize the design of nutrient formulations in the future. New treatment modalities for gastrointestinal dysfunction are being investigated and include small intestinal feeding, nonpharmacological options such as acupuncture, and drugs including novel motilin receptor agonists, and opioid antagonists. SUMMARY We are gradually developing a better understanding of how the gut works during critical illness, which has implications for optimizing the delivery of nutrition and thereby improving nutritional and clinical outcomes.
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Singer P, Pichard C. Reconciling divergent results of the latest parenteral nutrition studies in the ICU. Curr Opin Clin Nutr Metab Care 2013; 16:187-93. [PMID: 23385424 DOI: 10.1097/mco.0b013e32835c34be] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Recent studies on the optimal modalities to feed patients during the ICU stay show divergent results. The level and the timing of energy provision is a critical issue, associated with the clinical outcome. These results questioned the clinical relevance of the recent guidelines issued by American, Canadian and European academic societies. RECENT FINDINGS Four recent prospective randomized studies enrolled critically ill patients who received various nutritional regimens and tested the effect of nutritional support on outcome. The Tight Calorie balance Control Study (TICACOS) targeted on calorie administration according to measured energy expenditure and found increased ICU morbidity but improved hospital mortality. The large EpaNIC study compared 'early' with 'late' (parenteral nutrition) nutrition, mostly in patients after cardiac surgery, and found an increased morbidity associated with early parenteral nutrition. The supplemental parenteral nutrition (SPN) study randomized the patients after 3 days and targeted the calories administered by parenteral nutrition as a complement to unsuccessful enteral nutrition using indirect calorimetry. The SPN resulted in less nosocomial infections and shorter duration of mechanical ventilation. Finally, a recent Australian study enrolled patients unable to be early fed enterally to receive, or not, parenteral nutrition targeted at 1500 kcal. No complications were noted in the parenteral nutrition group. Lessons from all these studies are summarized and should help in designing better studies and guidelines. SUMMARY The critical analysis of recent prospective studies comparing various levels of calorie administration, enteral versus parenteral nutrition and enteral versus SPN confirms the recommendations to avoid underfeeding and overfeeding. Parenteral nutrition, required if enteral feeding is failing, and if adjusted up to a measured optimal level, may improve outcome. More studies on the optimal level of energy and protein administration to optimize the clinical outcome are required to fine tune current guidelines.
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Affiliation(s)
- Pierre Singer
- Department of General Intensive Care Medicine, Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
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Casaer MP, Mesotten D. Enteral nutrition: better navigation, yet unknown destination? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:1015. [PMID: 22136401 PMCID: PMC3388650 DOI: 10.1186/cc10538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The nutrition dose truly absorbed by a patient is crucial information in the management or the investigation of nutrition during critical illness. In the present issue of Critical Care, assessment of nutritional losses in stools was studied. These losses together with enteral nutrition lost in gastric fluids and enteral nutrition prescribed but never infused make up the difference between the dose supposedly given to a patient and the amount effectively taken up. Additionally, the optimal dosing and timing of nutrition during critical illness are still debated. When enteral nutrition is insufficient, the options are limited.
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