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Gomes AB, Barros DDSC, Sousa ABGPAD, Dos Santos LRA. Enteral glutamine for trauma patients in intensive care unit - Comment on: ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2024; 43:1522-1523. [PMID: 38733831 DOI: 10.1016/j.clnu.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Artur Barbosa Gomes
- Department of Nutrition, Federal University of Piauí - UFPI, Picos, Piauí, Brazil.
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2
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Liang B, Su J, Chen J, Shao H, Shen L, Xie B. Reply-letter to the editor: Enteral glutamine for trauma patients in intensive care unit - Comment on: ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2024; 43:1456-1458. [PMID: 38710126 DOI: 10.1016/j.clnu.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/08/2024]
Affiliation(s)
- Baofang Liang
- Department of Healthcare-associated Infection Management, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Jianwei Su
- Department of Clinical Pharmacy, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Jie Chen
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Hanquan Shao
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Lihan Shen
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China.
| | - Baocheng Xie
- Department of Pharmacy, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China.
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Tao W, Xu G, Zhou J, Luo Y, Li PS. Glutamine Supplementation on Burn Patients: A Systematic Review and Meta-analysis. J Burn Care Res 2024; 45:675-684. [PMID: 38243579 DOI: 10.1093/jbcr/irae007] [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: 07/11/2023] [Indexed: 01/21/2024]
Abstract
To evaluate the effect of glutamine supplement on patients with burns, we conducted a systematic review and meta-analysis via synthesizing up-to-date studies. Databases including PubMed, Cochrane Central Register, EMBASE, Google scholar, Wanfang data, and ClinicalTrials.gov were searched up to October 2023 to find randomized trials evaluating glutamine supplement on patients with burns. The main outcomes included hospital stay, in-hospital mortality, infection, and wound healing. Twenty-two trials that randomized a total of 2170 patients were included in this meta-analysis. Pooled the length of hospital stay was shortened by glutamine supplement (weighted mean differences [WMD] = -7.95, 95% confidence interval [CI] -10.53 to -5.36, I2 = 67.9%, 16 trials). Both pooled wound healing rates (WMD = 9.15, 95% CI 6.30 to 12.01, I2 = 82.7%, 6 studies) and wound healing times (WMD = -5.84, 95% CI -7.42 to -4.27, I2 = 45.7%, 7 studies) were improved by glutamine supplement. Moreover, glutamine supplement reduced wound infection (risk ratios [RR] = 0.38, 95% CI 0.21 to 0.69, I2 = 0%, 3 trials), but not nonwound infection (RR = 0.88, 95% CI 0.73 to 1.05, I2 = 39.6%, 9 trials). Neither in-hospital mortality (RR = 0.95, 95% CI 0.74 to 1.22, I2 = 36.0%, 8 trials) nor the length of intensive care unit stay (WMD = 1.85, 95% CI -7.24 to 10.93, I2 = 78.2%, 5 studies) was improved by glutamine supplement. Subgroup analysis showed positive effects were either influenced by or based on small-scale, single-center studies. Based on the current available data, we do not recommend the routine use of glutamine supplement for burn patients in hospital. Future large-scale randomized trials are still needed to give a conclusion about the effect of glutamine supplement on burn patients.
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Affiliation(s)
- Wei Tao
- Department of Burn and Plastic Surgery, Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, China
| | - Gang Xu
- Department of Burn and Plastic Surgery, Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, China
| | - Jie Zhou
- Department of Burn and Plastic Surgery, Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, China
| | - Yi Luo
- Department of Burn and Plastic Surgery, Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, China
| | - Ping-Song Li
- Department of Burn and Plastic Surgery, Clinical Medical College, Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, China
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Wunderle C, von Arx D, Mueller SC, Bernasconi L, Neyer P, Tribolet P, Stanga Z, Mueller B, Schuetz P. Association of Glutamine and Glutamate Metabolism with Mortality among Patients at Nutritional Risk-A Secondary Analysis of the Randomized Clinical Trial EFFORT. Nutrients 2024; 16:222. [PMID: 38257115 PMCID: PMC10821126 DOI: 10.3390/nu16020222] [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: 12/07/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Glutamine and its metabolite glutamate serve as the main energy substrates for immune cells, and their plasma levels drop during severe illness. Therefore, glutamine supplementation in the critical care setting has been advocated. However, little is known about glutamine metabolism in severely but not critically ill medical patients. We investigated the prognostic impact of glutamine metabolism in a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care in patients at nutritional risk. Among 234 patients with available measurements, low plasma levels of glutamate were independently associated with 30-day mortality (adjusted HR 2.35 [95% CI 1.18-4.67, p = 0.015]). The impact on mortality remained consistent long-term for up to 5 years. No significant association was found for circulating glutamine levels and short- or long-term mortality. There was no association of glutamate nor glutamine with malnutrition parameters or with the effectiveness of nutritional support. This secondary analysis found glutamate to be independently prognostic among medical inpatients at nutritional risk but poorly associated with the effectiveness of nutritional support. In contrast to ICU studies, we found no association between glutamine and clinical outcome.
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Affiliation(s)
- Carla Wunderle
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; (C.W.); (B.M.)
| | - Diana von Arx
- Medical Faculty, University of Basel, 4056 Basel, Switzerland
| | - Sydney Chiara Mueller
- Medical Faculty, University of Basel, 4056 Basel, Switzerland
- Faculty of Biomedical Scienes, Università della Svizzera italiana (USI), 6900 Lugano, Switzerland
| | - Luca Bernasconi
- Institute of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland (P.N.)
| | - Peter Neyer
- Institute of Laboratory Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland (P.N.)
| | - Pascal Tribolet
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; (C.W.); (B.M.)
- Department of Health Professions, Bern University of Applied Sciences, Murtenstrasse 10, 3008 Bern, Switzerland
- Faculty of Life Sciences, University of Vienna, Djerassiplatz 1, 1030 Vienna, Austria
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Beat Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; (C.W.); (B.M.)
- Faculty of Biomedical Scienes, Università della Svizzera italiana (USI), 6900 Lugano, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland; (C.W.); (B.M.)
- Medical Faculty, University of Basel, 4056 Basel, Switzerland
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5
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Liang B, Su J, Chen J, Shao H, Shen L, Xie B. Glutamine enteral therapy for critically ill adult patients: An updated meta-analysis of randomized controlled trials and trial sequential analysis. Clin Nutr 2024; 43:124-133. [PMID: 38041938 DOI: 10.1016/j.clnu.2023.11.011] [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: 09/21/2023] [Revised: 11/08/2023] [Accepted: 11/12/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND The efficacy of supplemental enteral glutamine (GLN) in critical illness patients remains uncertainty. OBJECTIVE Based on a recently published large-scale randomized controlled trials (RCTs) as regards the use of enteral GLN, we updated a meta-analysis of RCTs for further investigating the effects of enteral GLN administration in critically ill patients. METHODS We searched RCTs reporting the impact of supplemental enteral GLN about clinical outcomes in adult critical illness patients from EMBASE, PubMed, Clinical Trials.gov, Scopus and Web of Science and subsequently registered the protocol in the PROSPERO (CRD42023399770). RCTs of combined enteral-parenteral GLN or parenteral GLN only were excluded. Hospital mortality was designated as the primary outcome. We conducted subgroup analyses of primary outcome based on specific patient populations, dosages and therapy regimens, and further performed trial sequential analysis (TSA) for clinical outcomes. RESULTS Eighteen RCTs involving 2552 adult critically ill patients were identified. There were no remarkable influences on hospital mortality regardless of different subgroups (OR, 1.05; 95% CI, 0.85-1.30; p = 0.67), intensive care unit (ICU) length of stay (LOS) (MD, -0.07; 95% CI, -1.12 - 0.98; p = 0.89) and infectious complications (OR, 0.90; 95% CI, 0.75-1.10; p = 0.31) with enteral GLN supplementation. Additionally, the results of hospital mortality were confirmed by TSA. However, enteral GLN therapy was related to a reduction of hospital LOS (MD, -2.85; 95% CI, -5.27 to -0.43; p = 0.02). CONCLUSIONS In this meta-analysis, it seems that enteral GLN supplementation is unlikely ameliorate clinical outcomes in critical illness patients except for the reduction of hospital LOS. Our data do not support enteral GLN supplementation used routinely in critical illness patients.
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Affiliation(s)
- Baofang Liang
- Department of Healthcare-associated Infection Management, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Jianwei Su
- Department of Clinical Pharmacy, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Jie Chen
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Hanquan Shao
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China
| | - Lihan Shen
- Department of Critical Care Medicine, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China.
| | - Baocheng Xie
- Department of Pharmacy, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People's Hospital), Dongguan, Guangdong, China.
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Galindo-Martín CA, Cuellar-Mendoza D, Miño-Bernal JF, Pérez-Nieto OR, Kammar-García A, Phinder Puente ME. Letter to the Editor: Comments regarding the ESPEN clinical nutrition guideline for the administration of glutamine in burned patients and critically ill trauma patients. Clin Nutr 2024; 43:295-296. [PMID: 37993392 DOI: 10.1016/j.clnu.2023.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Carlos Alfredo Galindo-Martín
- Clinical Nutrition Department in the Intensive Care Unit, Hospital San Angel Inn Universidad, Ciudad de México, Mexico
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Radzikowska-Büchner E, Łopuszyńska I, Flieger W, Tobiasz M, Maciejewski R, Flieger J. An Overview of Recent Developments in the Management of Burn Injuries. Int J Mol Sci 2023; 24:16357. [PMID: 38003548 PMCID: PMC10671630 DOI: 10.3390/ijms242216357] [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: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.
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Affiliation(s)
- Elżbieta Radzikowska-Büchner
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Inga Łopuszyńska
- Department of Plastic, Reconstructive and Maxillary Surgery, National Medical Institute of the Ministry of the Interior and Administration, Wołoska 137 Street, 02-507 Warszawa, Poland;
| | - Wojciech Flieger
- Department of Human Anatomy, Medical University of Lublin, Jaczewskiego 4 Street, 20-090 Lublin, Poland;
| | - Michał Tobiasz
- Department of Plastic Surgery, Reconstructive Surgery and Burn Treatment, Medical University of Lublin, Krasnystawska 52 Street, 21-010 Łęczna, Poland;
| | - Ryszard Maciejewski
- Faculty of Medicine, University of Warsaw, Żwirki i Wigury 101 Street, 02-089 Warszawa, Poland;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A Street, 20-093 Lublin, Poland
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Weiss R, Meersch M, Gerke M, Wempe C, Schäfers M, Kellum JA, Zarbock A. Effect of Glutamine Administration After Cardiac Surgery on Kidney Damage in Patients at High Risk for Acute Kidney Injury: A Randomized Controlled Trial. Anesth Analg 2023; 137:1029-1038. [PMID: 36730070 DOI: 10.1213/ane.0000000000006288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after cardiac surgery and is associated with increased morbidity and mortality. However, no specific treatment options are available, emphasizing the need for preventive measures. The aim of this study was to clarify the effect of glutamine on [TIMP2]*[IGFBP7] levels at the end of the intervention period. METHODS In a randomized clinical, double-blind pilot study, 64 eligible cardiac surgery patients at high risk for AKI identified by high urinary [TIMP2]*[IGFBP7] were randomized, and body weight-adapted intravenous glutamine or saline-control was administered continuously for 12 hours postoperatively. The primary outcome was urinary [TIMP2]*[IGFBP7] at the end of the 12-hour study period. Secondary outcomes included kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) at 12 hours, overall AKI rates at 72 hours, free days through day 28 of mechanical ventilation and vasoactive medication, renal recovery at day 90, requirement of renal replacement therapy and mortality each at days 30, 60, and 90, length of intensive care unit (ICU) and hospital stay, and major adverse kidney events consisting of mortality, dialysis dependency, and persistent renal dysfunction (serum creatinine ≥2× compared to baseline value) at day 90 (major adverse kidney event; MAKE 90 ). RESULTS Sixty-four patients (mean age, 68.38 [standard deviation {SD} ± 10.48] years; 10 of 64 women) were enrolled and randomized. Patients received coronary artery bypass graft surgery (32/64), valve surgery (18/64), coronary artery bypass graft and valve surgery (6/64), or other procedures (8/64). Mean on-pump time was 68.38 (standard deviation ± 10.48) minutes. After glutamine administration, urinary [TIMP-2]*[IGFBP7] was significantly lower in the glutamine compared to the control group (primary end point, intervention: median, 0.18 [Q1, Q3; 0.09, 0.29], controls: median, 0.44 [Q1, Q3; 0.14, 0.79]; P = .01). In addition, [KIM-1] and [NGAL] were also significantly lower in the glutamine group. The overall AKI rate within 72 hours was not different among groups: (intervention 11/31 [35.5%] versus control 8/32 [25.0%]; P = .419; relative risk [RR], 0.86% [95% confidence interval {CI}, 0.62-1.20]). There were no differences regarding secondary end points. CONCLUSIONS Glutamine significantly decreased markers of kidney damage in cardiac surgery patients at high risk for AKI. Future trials have to be performed to investigate whether the administration of glutamine might be able to reduce the occurrence of AKI after cardiac surgery.
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Affiliation(s)
- Raphael Weiss
- From the Departments of Anesthesiology, Intensive Care and Pain Medicine
| | - Melanie Meersch
- From the Departments of Anesthesiology, Intensive Care and Pain Medicine
| | - Mena Gerke
- From the Departments of Anesthesiology, Intensive Care and Pain Medicine
| | - Carola Wempe
- From the Departments of Anesthesiology, Intensive Care and Pain Medicine
| | | | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alexander Zarbock
- From the Departments of Anesthesiology, Intensive Care and Pain Medicine
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9
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Greenhalgh DG, Hill DM, Burmeister DM, Gus EI, Cleland H, Padiglione A, Holden D, Huss F, Chew MS, Kubasiak JC, Burrell A, Manzanares W, Gómez MC, Yoshimura Y, Sjöberg F, Xie WG, Egipto P, Lavrentieva A, Jain A, Miranda-Altamirano A, Raby E, Aramendi I, Sen S, Chung KK, Alvarez RJQ, Han C, Matsushima A, Elmasry M, Liu Y, Donoso CS, Bolgiani A, Johnson LS, Vana LPM, de Romero RVD, Allorto N, Abesamis G, Luna VN, Gragnani A, González CB, Basilico H, Wood F, Jeng J, Li A, Singer M, Luo G, Palmieri T, Kahn S, Joe V, Cartotto R. Surviving Sepsis After Burn Campaign. Burns 2023; 49:1487-1524. [PMID: 37839919 DOI: 10.1016/j.burns.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes. METHODS The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported. RESULTS The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis. CONCLUSION Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.
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Affiliation(s)
- David G Greenhalgh
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA.
| | - David M Hill
- Department of Clinical Pharmacy & Translational Scre have been several studies that have evaluatedience, College of Pharmacy, University of Tennessee, Health Science Center; Memphis, TN, USA
| | - David M Burmeister
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Eduardo I Gus
- Division of Plastic & Reconstructive Surgery, The Hospital for Sick Children; Department of Surgery, University of Toronto, Toronto, Canada
| | - Heather Cleland
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Alex Padiglione
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Dane Holden
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University/Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John C Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, Monash University and Alfred Hospital, Intensive Care Research Center (ANZIC-RC), Melbourne, Australia
| | - William Manzanares
- Department of Critical Care Medicine, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - María Chacón Gómez
- Division of Intensive Care and Critical Medicine, Centro Nacional de Investigacion y Atencion de Quemados (CENIAQ), National Rehabilitation Institute, LGII, Mexico
| | - Yuya Yoshimura
- Department of Emergency and Critical Care Medicine, Hachinohe City Hospital, Hachinohe, Japan
| | - Folke Sjöberg
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wei-Guo Xie
- Institute of Burns, Tongren Hospital of Wuhan University (Wuhan Third Hospital), Wuhan, China
| | - Paula Egipto
- Centro Hospitalar e Universitário São João - Burn Unit, Porto, Portugal
| | | | | | | | - Ed Raby
- Infectious Diseases Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | | | - Soman Sen
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Chunmao Han
- Department of Burn and Wound Repair, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Moustafa Elmasry
- Department of Hand, Plastic Surgery and Burns, Linköping University, Linköping, Sweden
| | - Yan Liu
- Department of Burn, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Carlos Segovia Donoso
- Intensive Care Unit for Major Burns, Mutual Security Clinical Hospital, Santiago, Chile
| | - Alberto Bolgiani
- Department of Surgery, Deutsches Hospital, Buenos Aires, Argentina
| | - Laura S Johnson
- Department of Surgery, Emory University School of Medicine and Grady Health System, Georgia
| | - Luiz Philipe Molina Vana
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Nikki Allorto
- Grey's Hospital Pietermaritzburg Metropolitan Burn Service, University of KwaZulu Natal, Pietermaritzburg, South Africa
| | - Gerald Abesamis
- Alfredo T. Ramirez Burn Center, Division of Burns, Department of Surgery, University of Philippines Manila - Philippine General Hospital, Manila, Philippines
| | - Virginia Nuñez Luna
- Unidad Michou y Mau Xochimilco for Burnt Children, Secretaria Salud Ciudad de México, Mexico
| | - Alfredo Gragnani
- Disciplina de Cirurgia Plastica da Escola Paulista de Medicina da Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Carolina Bonilla González
- Department of Pediatrics and Intensive Care, Pediatric Burn Unit, Clinical Studies and Clinical Epidemiology Division, Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Hugo Basilico
- Intensive Care Area - Burn Unit - Pediatric Hospital "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina
| | - Fiona Wood
- Department of Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James Jeng
- Department of Surgery, University of California, Irvine, CA, USA
| | - Andrew Li
- Department of Surgery, Monash University and Alfred Hospital, Melbourne, Australia
| | - Mervyn Singer
- Department of Intensive Care Medicine, University College London, London, United Kingdom
| | - Gaoxing Luo
- Institute of Burn Research, Southwest Hospital, Army (Third Military) Medical University, Chongqing, China
| | - Tina Palmieri
- Department of Burns, Shriners Children's Northern California and Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven Kahn
- The South Carolina Burn Center, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine, CA, USA
| | - Robert Cartotto
- Department of Surgery, Sunnybrook Medical Center, Toronto, Ontario, Canada
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10
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Dou L, Peng Y, Zhang B, Yang H, Zheng K. Immune Remodeling during Aging and the Clinical Significance of Immunonutrition in Healthy Aging. Aging Dis 2023:AD.2023.0923. [PMID: 37815906 DOI: 10.14336/ad.2023.0923] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/23/2023] [Indexed: 10/12/2023] Open
Abstract
Aging is associated with changes in the immune system and the gut microbiota. Immunosenescence may lead to a low-grade, sterile chronic inflammation in a multifactorial and dynamic way, which plays a critical role in most age-related diseases. Age-related changes in the gut microbiota also shape the immune and inflammatory responses. Nutrition is a determinant of immune function and of the gut microbiota. Immunonutrion has been regarded as a new strategy for disease prevention and management, including many age-related diseases. However, the understanding of the cause-effect relationship is required to be more certain about the role of immunonutrition in supporting the immune homeostasis and its clinical relevance in elderly individuals. Herein, we review the remarkable quantitative and qualitative changes during aging that contribute to immunosenescence, inflammaging and microbial dysbiosis, and the effects on late-life health conditions. Furthermore, we discuss the clinical significance of immunonutrition in the treatment of age-related diseases by systematically reviewing its modulation of the immune system and the gut microbiota to clarify the effect of immunonutrition-based interventions on the healthy aging.
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Affiliation(s)
- Lei Dou
- Department of Geriatrics, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yang Peng
- Department of Geriatrics, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Bin Zhang
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Huiyuan Yang
- Department of Surgery, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Kai Zheng
- Department of Geriatrics, Tongji Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan 430030, China
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11
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Ortiz-Reyes L, Lee ZY, Chin Han Lew C, Hill A, Jeschke MG, Turgeon AF, Cancio L, Stoppe C, Patel JJ, Day AG, Heyland DK. The Efficacy of Glutamine Supplementation in Severe Adult Burn Patients: A Systematic Review With Trial Sequential Meta-Analysis. Crit Care Med 2023; 51:1086-1095. [PMID: 37114912 DOI: 10.1097/ccm.0000000000005887] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Evidence supporting glutamine supplementation in severe adult burn patients has created a state of uncertainty due to the variability in the treatment effect reported across small and large randomized controlled trials (RCTs). We aimed to systematically review the effect of glutamine supplementation on mortality in severe adult burn patients. DATA SOURCES MEDLINE, Embase, CINAHL, and Cochrane Central were searched from inception to February 10, 2023. STUDY SELECTION RCTs evaluating the effect of enteral or IV glutamine supplementation alone in severe adult burn patients were included. DATA EXTRACTION Two reviewers independently extracted data on study characteristics, burn injury characteristics, description of the intervention between groups, adverse events, and clinical outcomes. DATA SYNTHESIS Random effects meta-analyses were performed to estimate the pooled risk ratio (RR). Trial sequential analyses (TSA) for mortality and infectious complications were performed. Ten RCTs (1,577 patients) were included. We observed no significant effect of glutamine supplementation on overall mortality (RR, 0.65, 95% CI, 0.33-1.28; p = 0.21), infectious complications (RR, 0.83; 95% CI, 0.63-1.09; p = 0.18), or other secondary outcomes. In subgroup analyses, we observed no significant effects based on administration route or burn severity. We did observe a significant subgroup effect between single and multicenter RCTs in which glutamine significantly reduced mortality and infectious complications in singe-center RCTs but not in multicenter RCTs. However, TSA showed that the pooled results of single-center RCTs were type 1 errors and further trials would be futile. CONCLUSIONS Glutamine supplementation, regardless of administration, does not appear to improve clinical outcomes in severely adult burned patients.
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Affiliation(s)
- Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Aileen Hill
- Department of Anesthesiology and Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Marc G Jeschke
- Department of Surgery, McMaster University, Hamilton, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Quebec-Universite Laval Research Center, Quebec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Universite Laval, Quebec City, QC, Canada
| | - Leopoldo Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Christian Stoppe
- Department of Anesthesiology, Würzburg University, Würzburg, Germany
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin and Charite-Universitatsmedizin, Berlin, Germany
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Andrew G Day
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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12
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Meuli JN, Guiotto M, Elmers J, Mazzolai L, di Summa PG. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg 2023; 109:1360-1372. [PMID: 37057889 PMCID: PMC10389392 DOI: 10.1097/js9.0000000000000210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Microsurgical treatment options for lymphedema consist mainly of lymphovenous anastomosis (LVA) and vascularized lymph node transfers (VLNTs). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane, and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed, followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohorts, retrospective cohorts, and cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessel transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42020202417). No external funding was received for this review. RESULTS One hundred fifty studies, including 6496 patients, were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume, and change in the number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies, including 1002 patients, was -35.6% [95% CI: -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI: -19.8 to -45.6], and the overall pooled change in the number of cutaneous infections episodes per year across 8 studies including 248 patients was -1.9 [95% CI: -1.4 to -2.3]. The vast majority of the studies included were case series and cohorts, which were intrinsically exposed to a risk of selection bias. CONCLUSION The currently available evidence supports LVA and vascularized lymph node transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements, and reporting is paramount in future research in order to allow comparability across studies and pooling of results.
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Affiliation(s)
| | | | | | - Lucia Mazzolai
- Angiology Division, Heart and Vessel Department, Lausanne University Hospital, University of Lausanne, Switzerland
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13
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Hirschberger S, Schmid A, Kreth S. [Immunomodulation by nutritional intervention in critically ill patients]. DIE ANAESTHESIOLOGIE 2023; 72:229-244. [PMID: 36797533 PMCID: PMC9934515 DOI: 10.1007/s00101-023-01258-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 04/12/2023]
Abstract
Critically ill patients often suffer from a complex and severe immunological dysfunction. The differentiation and function of human immune cells are fundamentally controlled through metabolic processes. New concepts of immunonutrition therefore try to use enteral and parenteral nutrition to positively impact on the immune function of intensive care unit patients. This review article concisely presents the currently available evidence on the commonly used isolated supplements (anti-oxidative substances, amino acids, essential fatty acids) and difficulties related to their clinical use. The second part presents new and more comprehensive concepts of immunonutrition to influence the intestinal microbiome and to modulate the macronutrient composition. Immunonutrition of critically ill patients bears enormous potential and could become a valuable clinical tool for modulation of the immunometabolism of intensive care unit patients.
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Affiliation(s)
- Simon Hirschberger
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Annika Schmid
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland
| | - Simone Kreth
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland.
- Walter-Brendel-Zentrum für experimentelle Medizin, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 68, 81377, München, Deutschland.
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14
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Church A, Zoeller S. Enteral nutrition product formulations: A review of available products and indications for use. Nutr Clin Pract 2023; 38:277-300. [PMID: 36787985 DOI: 10.1002/ncp.10960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/16/2023] Open
Abstract
When oral nutrition is not feasible, enteral nutrition (EN) therapy is often considered the preferred route of nutrition support to meet the nutrient needs of individuals with a functional gastrointestinal tract across multiple levels of care (critical care, acute care, and home care). Enteral formulations have progressively evolved over the last 50 years from the simple blending of hospital food thin enough to run through a feeding tube, to the development of commercial standard formulas, followed by specialized formulas with immune-modulating and disease-specific qualities, to the most recent shift to food-based or blenderized EN composed of natural, whole foods with perceived health benefits. With the vast number of enteral formulations on the market, clinicians may be overwhelmed trying to determine proven vs theoretical benefits. This review is intended to explore differences in enteral formulations, identify implications for clinical practice, and review evidenced-based clinical guidelines to assist clinicians in enteral formula selection.
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Affiliation(s)
- April Church
- Nutrition Services, Asante Rogue Regional Medical Center, Medford, Oregon, USA
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15
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Ex Vivo Evaluation of Glutamine Treatment in Sepsis and Trauma in a Human Peripheral Blood Mononuclear Cells Model. Nutrients 2023; 15:nu15010252. [PMID: 36615909 PMCID: PMC9824313 DOI: 10.3390/nu15010252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/21/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
We aimed to assess the lipopolysaccharide (LPS), or heat shock (HS) induction, and glutamine-modulating effects on heat shock protein-90α (HSP90α) and cytokines in an ex vivo model using peripheral blood mononuclear cells (PBMCs). The PBMCs of patients with septic shock, trauma-related systemic inflammatory response syndrome (SIRS), and healthy subjects were incubated with 1 μg/mL LPS at 43 °C (HS). Glutamine 10 mM was added 1 hour before or after induction or not at all. We measured mRNA HSP90α, monocyte (m) and lymphocyte (l) HSP90α proteins, interleukin (IL)-1b, -6, -8, -10, tumor necrosis factor-α (TNF-α), and monocyte chemoattractant protein-1 (MCP-1) supernatant levels. Heat shock increased the HSP90α mRNA and mHSP90α in all groups (10-fold in sepsis, p < 0.001 and p = 0.047, respectively). LPS induced the mHSP90α and lHSP90α in healthy (p < 0.001) and mHSP90α in SIRS (p = 0.004) but not in sepsis. LPS induced the cytokines at 24 and 48 h in all groups, especially in trauma (p < 0.001); HS only induced the IL-8 in healthy (p = 0.003) and septic subjects (p = 0.05). Glutamine at 10 mM before or after stimulation did not alter any induction effect of LPS or HS on HSP90α mRNA and mHSP90α protein in sepsis. In SIRS, glutamine before LPS decreased the mHSP90α but increased it when given after HS (p = 0.018). Before or after LPS (p = 0.049) and before HS (p = 0.018), glutamine decreased the lHSP90α expression in sepsis but increased it in SIRS when given after HS (p = 0.003). Regarding cytokines, glutamine enhanced the LPS-induced MCP-1 at 48 h in healthy (p = 0.011), SIRS (p < 0.001), and sepsis (p = 0.006). In conclusion, glutamine at 10 mM, before or after LPS and HS, modulates mHSP90α and lHSP90α in sepsis and SIRS differently and unpredictably. Although it does not alter the stimulation effect on interleukins, glutamine enhances the LPS induction effect on supernatant MCP-1 in all groups. Future research should seek to elucidate better the impact of glutamine and temperature modulation on HSP90α and MCP-1 pathways in sepsis and trauma.
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16
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Mortada H, Alhindi N, Abukhudair A, Alanazi S, AlSahli A, Arab K. The Effects of Glutamine Supplementation on Reducing Mortality and Morbidity among Burn Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials. JPRAS Open 2022; 35:6-17. [PMID: 36578449 PMCID: PMC9791694 DOI: 10.1016/j.jpra.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/27/2022] Open
Abstract
Glutamine (GLN) has been proven to improve the prognosis of severely burned patients. GLN supplementation in critical illness has gained extreme popularity among researchers over the years, and its safety and efficacy are still under question. Therefore, we aim to study the role of GLN supplements in decreasing mortality, length of hospitalization (LOH), and infection in severely burned patients. PRISMA guidelines were used to design and conduct this systematic review. MEDLINE, Cochrane, and EMBASE databases were used to search for randomized controlled trials (RCTs) in January 2022. In order to assist in the search, MeSH terms such as burn injury, GLN, and RCT were used. As a result of reviewing the literature, 1112 publications were found. We included only 7 RCTs after implanting our inclusion criteria. There were 328 patients enrolled in the study, with 166 patients (50.61%) were allocated to GLN supplementation and 162 patients in the control groups (49.39%). The risk of infection was significantly lower among patients who received GLN supplementation than those in the control groups (RR = 0.41, 95% CI, 0.18 to 0.92, p = 0.030). The risk of death was significantly lower among GLN-receiving patients compared to non-GLN-receiving patients (RR = 0.09, 95% CI, 0.01 to 0.63, p = 0.016). GLN supplementation has been linked to lower hospital mortality and infection-related morbidity in burn patients. Furthermore, larger-scale and higher-quality studies are needed to assess whether there are any statistically and clinically significant changes.
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Affiliation(s)
- Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University and Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia,Corresponding author: Hatan Mortada, Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University, and Department of Plastic Surgery & Burn unit, King Saud Medical City, Riyadh, Saudi Arabia. PO Box 12161, Saudi Arabia, Mobile: 00966 54 668 0755
| | - Nawaf Alhindi
- Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | | | - Shahad Alanazi
- Division of Plastic Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Alaa AlSahli
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid Arab
- Division of Plastic Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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17
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Li Y, Liu H. Application strategy and effect analysis of nutritional support nursing for critically ill patients in intensive care units. Medicine (Baltimore) 2022; 101:e30396. [PMID: 36197233 PMCID: PMC9509121 DOI: 10.1097/md.0000000000030396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We investigate nutritional support and nursing status of critical patients in intensive care units (ICUs) to understand the latest nutritional support guidelines' implementation by clinical medical staff; identify problems in nutritional support and nursing for these patients, analyze causes, and present suggestions; and provide a clinical/theoretical bases to improve nutritional support implementation and nursing strategies for them. Clinical case information of 304 critically ill ICU patients admitted from July 2017 to July 2021 was analyzed. They were divided into the experimental (nutritional support) and control (no nutritional support) groups to compare their laboratory indicators, 28-day case fatality rate, and infection incidence. Least significant difference was used for postanalysis of statistically significant items to obtain pairwise comparisons. Nutrition support strategies for ICU patients are consistent with guidelines but have an implementation gap. No statistically significant differences were found in hemoglobin (HB), total serum protein (TP), serum albumin (ALB), transferrin (TF), prealbumin (PA), and total lymphocyte count (TLC) in experimental group patients compared with the control group within 24 hours (before nutritional support, P > .05). No statistically significant differences were also found in HB, TP, TLC, and ALB between the enteral nutrition + parenteral nutrition (EN + PN), total EN (TEN), total PN (TPN), and control groups on admission day 7 (after nutritional support, P > .05), while statistically significant differences existed between PA and TF (P < .05). TF of patients supported by TEN was higher (statistically significant difference, P < .05). PA in patients receiving TEN and EN + PN support was higher than in control group patients (statistically significant difference, P < .05). Compared with the control group, in experimental group patients, infection incidence was significantly lower (40.2% vs 62.9%, P < .05); incidence of complications was lower, but not statistically significant (40.2% vs 57.1%, P > .05); and 28-day mortalities were significantly lower (26.7% vs 45.7%, P < .05). Nutritional support can reduce hospitalization complications and 28-day mortality in critical patients, but its implementation must be standardized. Especially for patients with gastrointestinal dysfunction, personalized/standardized nutrition strategies and nursing procedures are needed when PN support is applied, and training of clinical medical staff should be strengthened to improve nutrition support's efficiency.
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Affiliation(s)
- Yunting Li
- Department of Emergency Medicine, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570311, China
| | - Haitang Liu
- Department of Critical Care Unit 2, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570311, China
- *Correspondence: Haitang Liu, Department of Critical Care Unit 2, The Second Affiliated Hospital of Hainan Medical University, Haikou, 570311, China (e-mail: )
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18
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Heyland DK, Wibbenmeyer L, Pollack J, Friedman B, Turgeon AF, Eshraghi N, Jeschke MG, Bélisle S, Grau D, Mandell S, Velamuri SR, Hundeshagen G, Moiemen N, Shokrollahi K, Foster K, Huss F, Collins D, Savetamal A, Gurney JM, Depetris N, Stoppe C, Ortiz-Reyes L, Garrel D, Day AG. A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. N Engl J Med 2022; 387:1001-1010. [PMID: 36082909 DOI: 10.1056/nejmoa2203364] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation. METHODS In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk. RESULTS A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed. CONCLUSIONS In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).
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Affiliation(s)
- Daren K Heyland
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Lucy Wibbenmeyer
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jonathan Pollack
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Bruce Friedman
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alexis F Turgeon
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Niknam Eshraghi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Marc G Jeschke
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sylvain Bélisle
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Daisy Grau
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Samuel Mandell
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sai R Velamuri
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Gabriel Hundeshagen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Naiem Moiemen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kayvan Shokrollahi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kevin Foster
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Fredrik Huss
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Declan Collins
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alisa Savetamal
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jennifer M Gurney
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Nadia Depetris
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Christian Stoppe
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Luis Ortiz-Reyes
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Dominique Garrel
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Andrew G Day
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
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Dewi NMRP, Harimawan AIW, Sanjaya IGPH, Samsarga GW. Enteral Glutamine Supplementation is Associated with Lowering Wound Infection Morbidity and Length of Hospital Stay among Burn Patients: A Meta-analysis and Systematic Review. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background. Significant nutritional support to meet increased energy expenditure is vital for burn patient's survival. Burn injury may lead to a significant decrease in Glutamine levels, which inspired the hypothesis that glutamine supplementation following burn injury would improve outcomes. Hence, the purpose of this meta-analysis study was to provide the rationale for determining the efficacy and safety of enteral glutamine in burn patients.
Methods. We conducted a meta-analysis based on PRISMA design to assess the potency of enteral glutamine supplementation as adjuvant treatment in patients with burn trauma. PubMed, Sciencedirect, and Google scholar were searched systematically using the following keywords: "enteral glutamine" and "burn patients" and "critical ill" and "infection" and "length of stay". Newcastle-Ottawa Scale (NOS) was used to assess the quality of papers included in our meta-analysis. A Z test was used to determine the significance of pooled effect estimates. Publication bias was assessed using Egger's. We used Comprehensive Meta-Analysis (CMA) version 2.1 to analyze the data.
Results: A total of 12 studies recording 344 cases and 335 controls were enrolled for our analysis. Data on hospital Length of Stay (LOS) was found that enteral glutamine supplementation provided a significant result in reducing the LOS (Std mean diff: 0.70, 95%CI: 0.16 – 1.24; p=0.0100). We also found that a higher risk of positive wound culture was significantly observed in patients without the supplementation of enteral glutamine (OR 2.15, 95% CI: 1.41 – 3.27; p=0.0003) compared to patients receiving enteral glutamine supplementation among burn patients.
Conclusion: In our meta-analysis study, enteral glutamine in burn patients confers significantly shorter LOS and lower risk of wound infection among burn patients. We suggest that enteral glutamine supplementation may be a beneficial intervention for the management of burn patients.
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Innate Immune System Response to Burn Damage-Focus on Cytokine Alteration. Int J Mol Sci 2022; 23:ijms23020716. [PMID: 35054900 PMCID: PMC8775698 DOI: 10.3390/ijms23020716] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 02/04/2023] Open
Abstract
In the literature, burns are understood as traumatic events accompanied by increased morbidity and mortality among affected patients. Their characteristic feature is the formation of swelling and redness at the site of the burn, which indicates the development of inflammation. This reaction is not only important in the healing process of wounds but is also responsible for stimulating the patient’s innate immune system. As a result of the loss of the protective ability of the epidermis, microbes which include bacteria, fungi, and viruses have easier access to the system, which can result in infections. However, the patient is still able to overcome the infections that occur through a cascade of cytokines and growth factors stimulated by inflammation. Long-term inflammation also has negative consequences for the body, which may result in multi-organ failure or lead to fibrosis and scarring of the skin. The innate immune response to burns is not only immediate, but also severe and prolonged, and some people with burn shock may also experience immunosuppression accompanied by an increased susceptibility to fatal infections. This immunosuppression includes apoptosis-induced lymphopenia, decreased interleukin 2 (IL-2) secretion, neutrophil storm, impaired phagocytosis, and decreased monocyte human leukocyte antigen-DR. This is why it is important to understand how the immune system works in people with burns and during infections of wounds by microorganisms. The aim of this study was to characterize the molecular pathways of cell signaling of the immune system of people affected by burns, taking into account the role of microbial infections.
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21
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Wang ZE, Zheng JJ, Bin Feng J, Wu D, Su S, Yang YJ, Wei Y, Chen ZH, Peng X. Glutamine relieves the hypermetabolic response and reduces organ damage in severe burn patients: A multicenter, randomized controlled clinical trial. Burns 2021; 48:1606-1617. [PMID: 34973853 DOI: 10.1016/j.burns.2021.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 11/07/2021] [Accepted: 12/15/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Severe burns can cause a hypermetabolic response and organ damage. Glutamine is a conditionally essential amino acid with various pharmacological effects. In this study, whether glutamine could alleviate the hypermetabolic response and maintain organ function after burn injury was analyzed. METHODS A multicenter, randomized, single-blind, parallel controlled trial was conducted to evaluate the efficacy of glutamine in decreasing hypermetabolism after burn injury. Physiological and biochemical indexes, such as vital signs, metabolic hormones, metabolic rate, and organ damage, were recorded on the 7th and 14th days after treatment. RESULTS In total, 55 adult burn patients with a total burn surface area (TBSA) of 30-70% were included in this study and randomly divided into the burn control (B, 28 patients) and burn+glutamine (B+G, 27 patients) groups. Except for the glutamine administration, the groups did not differ in the other treatments and nutrition supplements. The levels of diamine oxidase (DAO), lactulose/mannitol (L/M), β2-microglobulin, lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBD) and cardiac troponin l (cTnl) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). The levels of resting energy expenditure (REE), serum catecholamines, glucagon, lactate and Homeostasis model assessment (HOMA) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). No significant difference was found in the length of hospitalization or the mortality rate between the two groups (p > 0.05). CONCLUSIONS Glutamine moderately alleviates the hypermetabolic response and reduces organ damage after severe burns. Therefore, the early application of glutamine, which is effective and safe, should be used as an active intervention as early as possible.
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Affiliation(s)
- Zi En Wang
- Department of Burns, Union Hospital, Fujian Medical University, Fuzhou, China; Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Jian Jun Zheng
- Department of Burns, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Jin Bin Feng
- Department of Burn Surgery, No. 264 Hospital of PLA, Taiyuan, China
| | - Dan Wu
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Sen Su
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Yong Jun Yang
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Yan Wei
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Zhao Hong Chen
- Department of Burns, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Xi Peng
- Department of Burns, Union Hospital, Fujian Medical University, Fuzhou, China; Clinical Medical Research Center, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China; Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China; Shriners Burns Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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22
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Al-Dorzi HM, Arabi YM. Nutrition support for critically ill patients. JPEN J Parenter Enteral Nutr 2021; 45:47-59. [PMID: 34897737 DOI: 10.1002/jpen.2228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022]
Abstract
Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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23
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Alipanah-Moghadam R, Molazadeh L, Jafari-Suha Z, Naghizadeh-Baghi A, Mohajeri M, Nemati A. Glutamine supplementation can reduce some atherosclerosis markers after exhaustive exercise in young healthy males. Nutrition 2021; 94:111506. [PMID: 34844156 DOI: 10.1016/j.nut.2021.111506] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 08/29/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Glutamine can be beneficial to athletes for its antiinflammatory and antioxidant effects. The present study was designed to investigate the effect of glutamine supplementation on some atherosclerosis markers after exhaustive exercise in young healthy males. METHODS In an intervention study, 30 healthy males (case = 15 and control = 15) were randomly assigned into two groups. For 14 d, the intervention group received 0.3 g of glutamine per kilogram of body weight per day, with 25 g of sugar in 250 mL of water, and the control group received 25 g of sugar per 250 mL of water. At the end of the intervention, the participants completed one session of exhaustive exercise, and then fasting blood samples were taken to test serum levels of atherosclerosis markers. RESULTS In the intervention group, the serum levels of leptin, cholesterol, and oxidized low-density lipoprotein were lower than in the control group after 2 wk of glutamine supplementation (P < 0.05). Interleukin-6 serum levels were lower in the intervention group compared to the control group after supplementation, but not significantly. Serum levels of leptin, interleukin-6, cholesterol, and oxidized low-density lipoprotein, as well as the ratio of oxidized low-density lipoprotein to high-density lipoprotein, were significantly decreased in the intervention group compared to the control group after exhaustive exercise (P < 0.05). CONCLUSIONS Glutamine supplementation has beneficial effects for athletes, particularly those doing strenuous physical exercise, through reducing atherosclerosis-related biomarkers and elevating serum adiponectin levels, and it can potentially play a role in decreasing the initiation and progression of atherosclerosis.
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Affiliation(s)
- Reza Alipanah-Moghadam
- Department of Clinical Biochemistry, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Leila Molazadeh
- Department of Clinical Biochemistry, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Zeinab Jafari-Suha
- Department of Clinical Biochemistry, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | | | - Mahsa Mohajeri
- Digestive Disease Research Center, Ardabil University of Medical Sciences, Ardabil, Iran; Academic Center for Education, Culture and Research, Ardabil, Iran.
| | - Ali Nemati
- Department of Clinical Biochemistry, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran; Digestive Disease Research Center, Ardabil University of Medical Sciences, Ardabil, Iran.
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24
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Dmitriev AV, Machulina IA, Shestopalov AE. [Glutamine as a component of nutritional and metabolic therapy for surgical patients in ICU]. Khirurgiia (Mosk) 2021:98-106. [PMID: 34363451 DOI: 10.17116/hirurgia202108198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Glutamine is the most abundant amino acid in the human body that is involved in various metabolic processes. The development of hypermetabolic and hypercatabolic syndrome that accompanies critical conditions of ICU patients is associated with a decrease in the concentration of glutamine, especially in the blood plasma and muscles. This process may last for quite a long time and lead to a number of complications up to a fatal outcome. This review was aimed to analyze clinical studies conducted over the past 20 years that demonstrate the effect of intravenous infusion of glutamine dipeptide as part of balanced parenteral nutrition on the perioperative period: the severity of inflammatory response; the state of the intestinal mucosa; the incidence and severity of complications; mortality; the duration of stay in the ICU and hospital in general, etc. The analysis was performed using systematic reviews and meta-analyses based on randomized double-blind, placebo-controlled trials in different countries selected in the main databases (PubMed, EMBASE, Web of Science, The Cochrane Library, etc.). Most of the reports state that the inclusion of glutamine dipeptide in nutritional and metabolic therapy (NMT) in surgical patients reduces the frequency and severity of infectious complications and mortality, reduces the length of stay in ICU and in hospital in general, improves the biochemical parameters that reflect the condition of patients, and reduces the treatment costs. Thus, the conducted systematic reviews and meta-analyses confirm that the use of the parenteral form of glutamine dipeptide (Dipeptiven 20%) as part of balanced standard parenteral nutrition (PN) is a clinically and pharmacoeconomically justified strategy of NMT in surgical ICU patients.
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Affiliation(s)
- A V Dmitriev
- Northwest Society for Parenteral and Enteral Nutrition, Saint Petersbur, Northwest Society for Parenteral and Enteral Nutrition, Saint Petersburg
| | - I A Machulina
- SBHI City Clinical Hospital No. 70 named after E.O. Mukhin of the Moscow City Health Department, Mosco, SBHI City Clinical Hospital No. 70 named after E.O. Mukhin of the Moscow City Health Department, Moscow
| | - A E Shestopalov
- FSBE FPE Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Mosco, FSBE FPE Russian Medical Academy of Continuous Professional Education of the Ministry of Health of Russia, Moscow.,FSBI N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of Russia, Mosco, FSBI N.N. Burdenko Main Military Clinical Hospital of the Ministry of Defense of Russia, Moscow
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Berger MM, Binz PA, Roux C, Charrière M, Scaletta C, Raffoul W, Applegate LA, Pantet O. Exudative glutamine losses contribute to high needs after burn injury. JPEN J Parenter Enteral Nutr 2021; 46:782-788. [PMID: 34288001 PMCID: PMC9292800 DOI: 10.1002/jpen.2227] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Burnpatients characteristically have increased energy, glucose, and protein requirements. Glutamine supplementation is strongly recommended during early‐phase treatment and is associated with improved immunity, wound healing, and reduced mortality. This study evaluated if early burn exudative losses might contribute to higher supplementation needs. Methods Patients admitted to the burn intensive care unit (ICU) had exudate collection from tight bandages applied to arms or legs during the first week (exudate aliquot twice daily). Seven amino acids (alanine, arginine, cystEine, glutamine, leucine, lysine, and methionine) were quantified by liquid chromatography–mass spectrometry. Descriptive analysis of all results is provided as median and interquartile range or in value ranges. Results Eleven patients aged 19–77 years, presenting with burns on 18%–70% of the body surface, with a median simplified acute physiology score II of 33 (range, 16–56) were included during the study period. The highest amino acid losses were observed during the first 3 days with an important interpatient and intrapatient variability. Glutamine and alanine losses were highest, followed by leucine and lysine in all patients; amino acid exudate concentrations were in the range of normal plasma concentrations and were stable over time. Total glutamine losses were correlated to the burned surface (r2 = 0.552, P = .012), but not to enteral glutamine supplements. Conclusions The study shows significant exudative losses during early‐stage burn recovery and particularly for glutamine and alanine. Glutamine loss generally decreased with wound closure, the subsequent decline of exudation, and the evolving size of burn surfaces.
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Affiliation(s)
- Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Pierre-Alain Binz
- Clinical Chemistry Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Clothilde Roux
- Clinical Chemistry Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Mélanie Charrière
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Corinne Scaletta
- Unit of Regenerative Therapy, Service of Plastic, Reconstructive, and Hand Surgery, Department of Musculoskeletal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Wassim Raffoul
- Unit of Regenerative Therapy, Service of Plastic, Reconstructive, and Hand Surgery, Department of Musculoskeletal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lee Ann Applegate
- Unit of Regenerative Therapy, Service of Plastic, Reconstructive, and Hand Surgery, Department of Musculoskeletal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Pantet
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Moran JL. Multivariate meta-analysis of critical care meta-analyses: a meta-epidemiological study. BMC Med Res Methodol 2021; 21:148. [PMID: 34275460 PMCID: PMC8286437 DOI: 10.1186/s12874-021-01336-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022] Open
Abstract
Background Meta-analyses typically consider multiple outcomes and report univariate effect sizes considered as independent. Multivariate meta-analysis (MVMA) incorporates outcome correlation and synthesises direct evidence and related outcome estimates within a single analysis. In a series of meta-analyses from the critically ill literature, the current study contrasts multiple univariate effect estimates and their precision with those derived from MVMA. Methods A previous meta-epidemiological study was used to identify meta-analyses with either one or two secondary outcomes providing sufficient detail to structure bivariate or tri-variate MVMA, with mortality as primary outcome. Analysis was performed using a random effects model for both odds ratio (OR) and risk ratio (RR); borrowing of strength (BoS) between multivariate outcome estimates was reported. Estimate comparisons, β coefficients, standard errors (SE) and confidence interval (CI) width, univariate versus multivariate, were performed using Lin’s concordance correlation coefficient (CCC). Results In bivariate meta-analyses, for OR (n = 49) and RR (n = 48), there was substantial concordance (≥ 0.69) between estimates; but this was less so for tri-variate meta-analyses for both OR (n = 25; ≥ 0.38) and RR (≥ -0.10; n = 22). A variable change in the multivariate precision of primary mortality outcome estimates compared with univariate was present for both bivariate and tri-variate meta-analyses and for metrics. For second outcomes, precision tended to decrease and CI width increase for bivariate meta-analyses, but was variable in the tri-variate. For third outcomes, precision increased and CI width decreased. In bivariate meta-analyses, OR coefficient significance reversal, univariate versus MVMA, occurred once for mortality and 6 cases for second outcomes. RR coefficient significance reversal occurred in 4 cases; 2 were discordant with OR. For tri-variate OR meta-analyses reversal of coefficient estimate significance occurred in two cases for mortality, nine cases for second and 7 cases for third outcomes. In RR meta-analyses significance reversals occurred for mortality in 2 cases, 6 cases for second and 3 cases for third; there were 7 discordances with OR. BoS was greater in trivariate MVMAs compared with bivariate and for OR versus RR. Conclusions MVMA would appear to be the preferred solution to multiple univariate analyses; parameter significance changes may occur. Analytic metric appears to be a determinant.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, 5011, Australia.
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Montejo González JC, de la Fuente O'Connor E, Martínez-Lozano Aranaga F, Servià Goixart L. Recommendations for specialized nutritional-metabolic treatment of the critical patient: Pharmaconutrients, specific nutrients, fiber, synbiotics. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:39-43. [PMID: 32532409 DOI: 10.1016/j.medin.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
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Santos HO, Tinsley GM, da Silva GAR, Bueno AA. Pharmaconutrition in the Clinical Management of COVID-19: A Lack of Evidence-Based Research But Clues to Personalized Prescription. J Pers Med 2020; 10:jpm10040145. [PMID: 32992693 PMCID: PMC7712662 DOI: 10.3390/jpm10040145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023] Open
Abstract
A scientific interest has emerged to identify pharmaceutical and nutritional strategies in the clinical management of coronavirus disease 2019 (COVID-19). The purpose of this narrative review is to critically assess and discuss pharmaconutrition strategies that, secondary to accepted treatment methods, could be candidates in the current context of COVID-19. Oral medicinal doses of vitamin C (1–3 g/d) and zinc (80 mg/d elemental zinc) could be promising at the first signs and symptoms of COVID-19 as well as for general colds. In critical care situations requiring parenteral nutrition, vitamin C (3–10 g/d) and glutamine (0.3–0.5 g/kg/d) administration could be considered, whereas vitamin D3 administration (100,000 IU administered intramuscularly as a one-time dose) could possess benefits for patients with severe deficiency. Considering the presence of n-3 polyunsaturated fatty acids and arginine in immune-enhancing diets, their co-administration may also occur in clinical conditions where these formulations are recommended. However, despite the use of the aforementioned strategies in prior contexts, there is currently no evidence of the utility of any nutritional strategies in the management of SARS-CoV-2 infection and COVID-19. Nevertheless, ongoing and future clinical research is imperative to determine if any pharmaconutrition strategies can halt the progression of COVID-19.
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Affiliation(s)
- Heitor O. Santos
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia 38408-100, Brazil
- Correspondence: ; Tel.: +55-34-992112948; Fax: +55-34-3225-8628
| | - Grant M. Tinsley
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA;
| | - Guilherme A. R. da Silva
- Hospital Universitário Gaffrée e Guinle, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro 21941-901, Brazil;
| | - Allain A. Bueno
- College of Health, Life and Environmental Sciences, University of Worcester, Worcester WR2 6AJ, UK;
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Yang YJ, Liu MM, Zhang Y, Wang ZE, Dan-Wu, Fan SJ, Wei Y, Xia L, Peng X. Effectiveness and mechanism study of glutamine on alleviating hypermetabolism in burned rats. Nutrition 2020; 79-80:110934. [PMID: 32847775 DOI: 10.1016/j.nut.2020.110934] [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: 12/16/2019] [Revised: 06/14/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study aimed to explore the effects of glutamine on hypermetabolic reactions in burned rats and its underlying mechanism. METHODS Fifty-five Sprague-Dawley rats were randomly divided into three groups, namely, the control (C), burned (B), and burned + glutamine (B + G) groups. Rats in the glutamine treatment group were supplemented with 1 g glutamine per kg body weight. Changes in body weight and resting energy expenditure in all groups were observed daily. Blood glucose and glucose tolerance level were measured on days 1, 3, 7, 10 and 14 after burn injury. On days 7 and 14 after injury, the rats were sacrificed, and the weight and protein content of the skeletal muscle were measured. Moreover, the level of glutamine, inflammatory mediator, nicotinamide adenine dinucleotide phosphate (NADPH), glutathione, and the activity of glutamine metabolic enzymes were measured. RESULTS The hypermetabolic reaction after burn injury was significantly inhibited by glutamine administration, and the range of variations in the resting energy expenditure and body weight indicators was narrowed remarkably (P < 0.05 or 0.01), whereas the weight and protein content of the skeletal muscle returned to normal (P < 0.05 or 0.01). Glutamine could increase glutaminase activity in various tissues, promote the utilization of glutamine, and appropriately reduce the degree of organ damage and inflammatory response (P < 0.05 or 0.01). Furthermore, glutamine could promote the synthesis of the reducing substances NADPH and glutathione (P < 0.05 or 0.01). CONCLUSIONS Glutamine administration effectively reduces hypermetabolic reactions by promoting NADPH synthesis, inhibiting oxidative stress, and improving glutamine utilization after burn injury.
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Affiliation(s)
- Yong-Jun Yang
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Man-Man Liu
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Yong Zhang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Zi En Wang
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China; Department of Burns, Union Hospital, Fujian Medical University, Fuzhou China
| | - Dan-Wu
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Shi-Jun Fan
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Yan Wei
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Lin Xia
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Xi Peng
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China; Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China; Department of Burns, Union Hospital, Fujian Medical University, Fuzhou China; Shriners Burns Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Apostolopoulou A, Haidich AB, Kofina K, Manzanares W, Bouras E, Tsaousi G, Stoppe C, Dardavessis TI, Chourdakis M. Effects of glutamine supplementation on critically ill patients: Focus on efficacy and safety. An overview of systematic reviews. Nutrition 2020; 78:110960. [PMID: 32877810 DOI: 10.1016/j.nut.2020.110960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this overview of systematic reviews was to synthesize, appraise, and present all systematic review (SR) evidence on the clinical efficacy of glutamine administration to severely ill patients. METHODS Medline, Scopus, the Cochrane Library, and Prospero were searched up to March 2020. Systematic reviews and meta-analyses of randomized controlled trials published in English, comparing immunomodulating diets-containing exclusively glutamine-with standard diets for critically ill adult patients were selected. Data were collected from each selected systematic review and all available primary studies. The primary outcome was overall mortality; secondary outcomes were rate of infectious complications, hospital and intensive care unit (ICU) length of stay (LOS). RESULTS Seventeen SRs were eligible for inclusion. Of the SRs, 16 included meta-analyses with moderate degree of overlap (corrected covered area = 10%). These included 117 randomized controlled trials with 9933 patients. Glutamine supplementation was not associated with overall mortality and ICU LOS. However, it may reduce the rate of infectious complications overall (N = 3666, risk ratio, 0.82; 95% confidence interval [CI], 0.73-0.92; I2 = 33%: low quality of evidence). LOS was limited with the supplementation of glutamine (N = 4353 weighted mean difference, -2.90; 95% CI, -3.66 to -2.15; I2 = 81%: very low quality of evidence), but this effect was diminished when only studies with low risk for bias were synthesized. CONCLUSION Glutamine could demonstrate a beneficial role in critical care patients of diminishing the rate of infectious complications and hospital and ICU LOS. However, future studies with better quality would confirm this finding.
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Affiliation(s)
- Aikaterini Apostolopoulou
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Anna-Bettina Haidich
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Konstantinia Kofina
- First University Surgical Department, Faculty of Medicine, Democritus University of Thrace, University Campus, Alexandroupolis, Greece
| | - William Manzanares
- Department of Critical Care, University Hospital. Faculty of Medicine, Universidad de la República, Montevideo, Uruguay
| | - Emmanouil Bouras
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Anesthesiology and ICU, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Christian Stoppe
- Department of Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Theodoros I Dardavessis
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece
| | - Michail Chourdakis
- Laboratory of Hygiene, Social & Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, Greece.
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Prevention of Severe Intestinal Barrier Dysfunction Through a Single-Species Probiotics is Associated With the Activation of Microbiome-Mediated Glutamate-Glutamine Biosynthesis. Shock 2020; 55:128-137. [PMID: 32694391 DOI: 10.1097/shk.0000000000001593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Intra-abdominal hypertension (IAH), the leading complication in the intensive care unit, significantly disturbs the gut microbial composition by decreasing the relative abundance of Lactobacillus and increasing the relative abundance of opportunistic infectious bacteria. METHODS To evaluate the preventative effect of Lactobacillus-based probiotics on IAH-induced intestinal barrier damages, a single-species probiotics (L92) and a multispecies probiotics (VSL#3) were introduced orally to Sprague-Dawley rats for 7 days before inducing IAH. The intestinal histology and permeability to macromolecules (fluoresceine isothiocyanate, FITC-dextran, N = 8 for each group), the parameters of immunomodulatory and oxidative responses [monocyte chemotactic protein 1 (MCP-1), interleukin-1β (IL-1β), interleukin-4 (IL-4), interleukin-10 (IL-10), malonaldehyde, glutathione peroxidase (GSH- Px), catalase (CAT), and superoxide dismutase; N = 4 for each group], and the microbiome profiling (N = 4 for each group) were analyzed. RESULTS Seven-day pretreatments of L92 significantly alleviated the IAH-induced increase in intestinal permeability to FITC-dextran and histological damage (P < 0.0001), accompanied with the suppression of inflammatory and oxidative activation. The increase of MCP-1 and IL-1β was significantly inhibited (P < 0.05); the anti-inflammatory cytokines, IL-4, and IL-10 were maintained at high levels; and the suppression of CAT (P < 0.05) was significantly reversed when pretreated with L92. On the contrary, no significant protective effects were observed in the VSL#3-pretreated group. Among the 84 identified species, 260 MetaCyc pathways, and 217 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways, the protective effects of L92 were correlated with an increased relative abundance of Bacteroides finegoldii, Odoribacter splanchnicus, and the global activation of amino acid biosynthesis pathways, especially the glutamate-glutamine biosynthesis pathway. CONCLUSIONS Seven-day pretreatment with a single-species probiotics can prevent IAH-induced severe intestinal barrier dysfunction, potentially through microbial modulation.
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ALAKAYA M, ÇITAK EÇ, TAŞKINLAR S, YILMAZ SN, ÖZÇİMEN AA, ÇİMEN MYB. Glutamin ve β-hidroksi β-metil bütiratin metotreksatin indüklediği intestinal mukozit üzerine etkisi. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.648558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Legrand M, Barraud D, Constant I, Devauchelle P, Donat N, Fontaine M, Goffinet L, Hoffmann C, Jeanne M, Jonqueres J, Leclerc T, Lefort H, Louvet N, Losser MR, Lucas C, Pantet O, Roquilly A, Rousseau AF, Soussi S, Wiramus S, Gayat E, Blet A. Management of severe thermal burns in the acute phase in adults and children. Anaesth Crit Care Pain Med 2020; 39:253-267. [PMID: 32147581 DOI: 10.1016/j.accpm.2020.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children. DESIGN A committee of 20 experts was asked to produce recommendations in six fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion. RESULTS The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations. CONCLUSION Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, San Francisco, United States.
| | - Damien Barraud
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France
| | - Isabelle Constant
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | | | - Nicolas Donat
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Mathieu Fontaine
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Laetitia Goffinet
- Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France
| | | | - Mathieu Jeanne
- CHU Lille, Anaesthesia and Critical Care, Burn Centre, 59000 Lille, France; University of Lille, Inserm, CHU Lille, CIC 1403, 59000 Lille, France; University of Lille, EA 7365 - GRITA, 59000 Lille, France
| | - Jeanne Jonqueres
- Burn Intensive Care Unit, Saint-Joseph Saint-Luc Hospital, 20, quai Claude-Bernard, 69007 Lyon, France
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France
| | - Hugues Lefort
- Department of emergency medicine, Legouest Military Teaching Hospital, Metz, France
| | - Nicolas Louvet
- Anaesthesiology Department, Hôpital Armand-Trousseau, Sorbonne Université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Marie-Reine Losser
- Hôpital de Mercy, Intensive Care Medicine and Burn Centre, CHR Metz-Thionville, Ars-Laquenexy, France; Paediatric Burn Centre, University Hospital of Nancy, 54511 Vandœuvre-Lès-Nancy, France; Inserm UMR 1116, Team 2, 54000 Nancy, France; University of Lorraine, 54000 Nancy, France
| | - Célia Lucas
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France
| | - Olivier Pantet
- Service of Adult Intensive Care Medicine and Burns, Lausanne University Hospital (CHUV), BH 08-651, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Antoine Roquilly
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, Nantes, France; Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University of Nantes, Nantes, France
| | | | - Sabri Soussi
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Interdepartmental Division of Critical Care, Keenan Research Centre for Biomedical Science and Institute of Medical Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sandrine Wiramus
- Department of Anaesthesia and Intensive Care Medicine and Burn Centre, University Hospital of Marseille, La Timone Hospital, Marseille, France
| | - Etienne Gayat
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France
| | - Alice Blet
- Department of Anaesthesiology, Critical Care and Burn Centre, Lariboisière-Saint-Louis Hospitals, DMU Parabol, AP-HP Nord, University of Paris, Paris, France; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), University of Paris, Paris, France; Department of Research, University of Ottawa Heart Institute, Ottawa, ON, Canada
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Taha H, Steinke B, Fischer H, Malcharek MJ, Kremer T, Gille J. A 'metabolic bundle' including Oxandrolone in optimising the metabolic status of severely burn injured patients: a retrospective analysis of the first 50 patients. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2019; 8:Doc17. [PMID: 31815086 PMCID: PMC6883381 DOI: 10.3205/iprs000143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: Severe burn injuries are associated with a rapid escalating hypermetabolic state and catabolism of muscle mass. To ameliorate this process a standardized approach using pharmacological and non-pharmacological interventions was implemented within a single burns center. Whilst individual components of this standardized package are well documented in the literature, their collective or bundled effect has not as yet been assessed. The aim of this study was to evaluate the efficacy of this standardized bundle of metabolic modulators and assess the safety of including the anabolic steroid oxandrolone within it. Methods: This retrospective observational study constituted all patients in whom the metabolic bundle including oxandrolone therapy was applied. The other elements of the metabolic bundle consisted of early surgical burn excision within seven days to completion, early active mobilization, increased ambient room temperature, expediated carbohydrate and protein rich enteral feeding with glutamine and trace element supplements (such as copper and zinc). Finally, administration of propranolol as a non-selective beta-blocker. Data collection was through review of the patient data management system focusing on the outcome criteria and hepatic blood values. Results: The study looked at fifty consecutive patients meeting the inclusion criteria. Median patient age and burned total body surface area (TBSA) were 62 years [51.75; 73] and 33.75% [24.75; 51] respectively with an abbreviated burn severity index (ABSI) of 10 [9; 10.25]. Definitive surgical burn wound excision was completed in 44 patients [88%] within 7 days. 39 patients (78%) received propranolol over a therapeutic period of 29 days [19; 44]. Glutamine was supplemented in 45 patients (90%), while zinc and copper were applied to 42 (84%) and 31 (62%) respectively. Significant low zinc values were noted at therapeutic onset (6.5 mmol/l [4.7; 7.9]) requiring sustained substitution over 37.5 days [22; 46.75]). In respect of the inclusion criteria, all patients received oxandrolone at 20 mg/day [20; 20]. This was commenced on day 6.5 [4; 14] post burn injury and continued over 26 days [19; 31]. Despite a transitory elevation of hepatic enzyme values (ALT, GGT), these were only clinically relevant (>10 µmol/l*S) in 2.4% and 4.6% of all measurements respectively. None were sufficiently of concern to merit cessation of treatment. Conclusion: The application of a standardised bundle of metabolic treatment options of severe burns injured patients is reliable, repeatable and safe. Potential concerns of oxandrolone treatment regarding hepatic compromise remain unfounded.
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Affiliation(s)
- Hischam Taha
- Department of Plastic and Hand Surgery with burn care unit, St. Georg Hospital gGmbH Leipzig, Germany
| | - Björn Steinke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, St. Georg Hospital gGmbH Leipzig, Germany
| | - Hagen Fischer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, St. Georg Hospital gGmbH Leipzig, Germany
| | - Michael J Malcharek
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, St. Georg Hospital gGmbH Leipzig, Germany
| | - Thomas Kremer
- Department of Plastic and Hand Surgery with burn care unit, St. Georg Hospital gGmbH Leipzig, Germany
| | - Jochen Gille
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, St. Georg Hospital gGmbH Leipzig, Germany
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Lopez-Delgado JC, Muñoz-del Rio G, Flordelís-Lasierra JL, Putzu A. Nutrition in Adult Cardiac Surgery: Preoperative Evaluation, Management in the Postoperative Period, and Clinical Implications for Outcomes. J Cardiothorac Vasc Anesth 2019; 33:3143-3162. [DOI: 10.1053/j.jvca.2019.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 02/07/2023]
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Antioxidant and Trace Element Supplementation Reduce the Inflammatory Response in Critically Ill Burn Patients. J Burn Care Res 2019; 39:1-9. [PMID: 28877128 DOI: 10.1097/bcr.0000000000000607] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022]
Abstract
Oxidative stress after burn injury induces inflammatory and hypermetabolic responses associated with adverse outcomes. We propose that antioxidant and trace element supplementation may reduce oxidative stress and subsequently alleviate inflammation and hypermetabolism, thus improving clinical outcomes. We conducted a cohort study of adult patients with an acute burn injury admitted to our provincial burn center. Patients in the antioxidant group received an intravenous infusion of multivitamins and trace elements for the first 14 days after admission. The inflammatory profile was assessed at early time points, < 14 days postburn, and later time points, ≥ 15 days postburn, and included interleukin (IL)-1β, interferon-γ, IL-1 receptor antagonist, IL-6, granulocyte-macrophage colony-stimulating factor, and FMS-like tyrosine kinase 3 ligand. Hypermetabolism was assessed by resting energy expenditure. Clinical outcomes included mortality, morbidities, hospital length of stay, and infections including days to the last positive culture after injury. We studied 172 patients, mean age 49 ± 17 years and 33 ± 13% TBSA burned, with 91 controls and 81 patients in the antioxidant group. Patients in the antioxidant group had significantly lower levels of inflammatory markers at both early and late time points, P < .05. Antioxidant treatment was associated with decreased measure of hypermetabolism, P < .05. Morbidity and mortality were not significantly different between groups. Length of hospital stay was significantly shorter in the antioxidant group when adjusted for patient demographics and injury characteristics (risk ratio (RR), 0.78; 95% confidence interval (CI), 0.66-0.92). In the antioxidant group, while infections were not different, the last positive culture post-injury was documented at median 19 days (Interquartile range (IQR), 11-43 days) compared with controls at 35 days (IQR, 15-59 days), P = .012. Patients receiving antioxidant and trace element supplementation had reduced markers of burn stress-induced inflammation; they were also associated with a decreased hypermetabolic response, shorter length of stay, and improved bacterial clearance.
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Abstract
Nutritional support is seen as a vital component in the battle to attenuate the extreme hypermetabolic response experienced by patients suffering from large thermal injuries. Protein catabolism precipitating protein malnutrition places patients at greater risk of wound infection and sepsis due to delayed wound healing. Underfeeding, aggressive feeding, feeding routes, timing of initiation of feeding and tight insulin control have all been explored extensively in the quest to understand what nutritional treatment will best attenuate the hypermetabolic response. Despite this it is suggested that the majority of patients with large thermal injuries do not receive adequate nutritional support immediately post injury. Nurses have a pivotal role to play in ensuring that thermal injury patients receive appropriate nutritional support based on the best available evidence.
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Affiliation(s)
- Christina Price
- Wound Care Nurse Specialist/Staff Trainer, Bethesda General Hospital, Serukam, Singkawang, West Borneo, Indonesia
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Parenteral amino acid supplementation with high-dose insulin prevents hypoaminoacidemia during cardiac surgery. Nutrition 2019; 69:110566. [PMID: 31539818 DOI: 10.1016/j.nut.2019.110566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 06/26/2019] [Accepted: 07/07/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Surgery triggers a stress response that produces insulin resistance and hyperglycemia. During cardiac surgery, the administration of high-dose insulin along with dextrose titration maintains normoglycemia, but dramatically decreases plasma amino acids (AAs) compared with preoperative fasting levels. Hypoaminoacidemia limits protein synthesis and prevents anabolic responses after surgery. We investigated whether parenteral infusion of AAs during and immediately after cardiac surgery would prevent hypoaminoacidemia in patients who receive high-dose insulin therapy. METHODS Sixteen patients undergoing coronary artery bypass grafting surgery were randomly allocated to receive AAs with % kcal equivalent to either 20% (n = 8) or 35% (n = 8) of their measured resting energy expenditure (REE). Insulin was infused at a constant rate of 5 mU/(kg × min), whereas dextrose was titrated to maintain normoglycemia during and until 5 h after surgery. Plasma AA concentrations were measured at baseline before and after surgery. RESULTS Compared with the 20% AA group after surgery, AA concentrations were significantly higher in the 35% AA group for 12 of 20 AAs (P < 0.032), including all branched-chain AAs. In the 20% AA group, total essential AAs decreased by 21% and nonessential AAs decreased by 14% after surgery compared with preoperative fasting levels. In contrast, giving 35% AAs prevented this unfavorable decrease in AAs, and in fact allowed for a 23% and 12% increase in essential and nonessential AAs, respectively. CONCLUSIONS AA supplementation at 35% REE, but not 20% REE, can effectively prevent hypoaminoacidemia caused by high-dose insulin therapy during cardiac surgery.
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Abstract
Burn injury is the most devastating of survivable injuries and is a worldwide public health crisis. Burn injury is among the most severe metabolic stresses a patient can sustain. A major burn leads to an inflammatory response and catabolism that, when compounded by burn wound nutrient losses, can lead to severe nutrition losses and deficiencies. These losses can impair immune function and wound healing and place burn patients at high risk for organ injury and mortality. Experimental data indicate glutamine (GLN) is well positioned mechanistically, perhaps above and beyond in any other intensive care unit setting, to improve outcome in burn-injured patients. Initial clinical trial data have also shown a consistent signal of reduced mortality and reduced hospital length of stay in burn-injured subjects, without signals of clinical risk. A number of GLN clinical trials demonstrate significant reductions of gram-negative bacteremia in burn injury, perhaps via maintenance of the gut barrier or gut immune function. Current societal recommendations continue to suggest the use of GLN in burn injury. The promising clinical data in burn-injured patients, with no signals of harm, have warranted study of GLN in the definitive RE-ENERGIZE trial, which is now ongoing.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology and Duke Clinical Research Institute, Duke University Hospital, Durham, North Carolina, USA
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Xiong LJ, Shang LH, Ou XQ, Li Y, Xie XL. [Clinical effect of alanyl-glutamine-enriched nutritional support in the treatment of children with abdominal Henoch-Schönlein purpura]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:168-171. [PMID: 30782281 PMCID: PMC7389839 DOI: 10.7499/j.issn.1008-8830.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/07/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To study the clinical effect of alanyl-glutamine-enriched nutritional support in the treatment of children with abdominal Henoch-Schönlein purpura. METHODS Children with abdominal Henoch-Schönlein purpura who needed nutritional support were enrolled and stratified according to age, sex and the severity of disease, and were randomly divided into a control group (n=118) and an enriched nutritional support group (n=107). The control group was given nutritional support without using alanyl-glutamine, while the enriched nutritional support group was given alanyl-glutamine-enriched nutritional support. Intravenous steroids were used according to the severity of disease in both groups. Other therapies were the same in the two groups. The two groups were compared in terms of the length of hospital stay, the rate and duration of use of intravenous steroids, the recurrence rate of symptoms during hospitalization, the rate of total parenteral nutrition (TPN), the rate of weight loss and the rate of fasting for more than 5 days. All patients were followed up for 3 months after discharge to monitor the recurrence of symptoms. RESULTS There were no significant differences in the length of hospital stay, the rate of TPN and the rate of fasting for more than 5 days between the two groups (P>0.05). Compared with the enriched nutritional support group, the control group showed significant increases in the rate and duration of use of intravenous steroids, the recurrence rate of symptoms and the rate of weight loss (P<0.05). After the 3-month follow-up, all the children resumed normal diet, and the recurrence rate of digestive symptoms was less than 20% in each group. Abdominal pain was the most common symptom (83.33%, 30/36), followed by vomiting and abdominal distention. No digestive hemorrhage was observed. All the symptoms were relieved after symptomatic treatment. No significant difference was found between the two groups in the recurrence rate of digestive symptoms (P=0.693). CONCLUSIONS Alanyl-glutamine-enriched nutritional support in the treatment of children with abdominal Henoch-Schönlein purpura can reduce the use of intravenous steroids and weight loss, but without impact on the length of hospital stay and post-discharge recurrence.
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Affiliation(s)
- Li-Jing Xiong
- Department of Pediatric Gastroenterology, Chengdu Women and Children's Central Hospital, Chengdu 610091, China.
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Association of intestinal permeability with a NUTRIC score in critically ill patients. Nutrition 2019; 63-64:1-8. [PMID: 30925269 DOI: 10.1016/j.nut.2019.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/12/2018] [Accepted: 01/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the association of intestinal permeability with the Nutrition Risk in Critically Ill (NUTRIC) score and the modified NUTRIC score (mNUTRIC) in intensive care unit (ICU) hospitalized patients. METHODS One hundred and fifty ICU hospitalized adult patients admitted between October 2017 and April 2018 who stayed for >24 h in the general ICU were enrolled in the study. Nutrition status was estimated using the NUTRIC score, an ICU-specific nutrition risk assessment tool. The NUTRIC score was calculated using the exact same thresholds and point system as developed previously. Admission plasma endotoxin and zonulin concentrations were measured to assess intestinal permeability. RESULTS Median plasma endotoxin and zonulin increased with increasing mNUTRIC and NUTRIC categories in the overall study population and in the glutamine-deficient subgroup. Multivariate binary logistic regression analyses showed a significant association between the plasma endotoxin (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.8-3.52) and zonulin (OR, 1.11; 95% CI, 1.03-1.20) levels with NUTRIC category in the overall population and the glutamine-deficient subgroup. Similar results were obtained when using mNUTRIC. CONCLUSIONS Results from the present study provided evidence that higher plasma endotoxin and zonulin levels are associated with a progressively higher NUTRIC score in critically ill patients.
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Dushianthan A, Cusack R, Burgess VA, Grocott MPW, Calder PC. Immunonutrition for acute respiratory distress syndrome (ARDS) in adults. Cochrane Database Syst Rev 2019; 1:CD012041. [PMID: 30677127 PMCID: PMC6353063 DOI: 10.1002/14651858.cd012041.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is an overwhelming systemic inflammatory process associated with significant morbidity and mortality. Pharmacotherapies that moderate inflammation in ARDS are lacking. Several trials have evaluated the effects of pharmaconutrients, given as part of a feeding formula or as a nutritional supplement, on clinical outcomes in critical illness and ARDS. OBJECTIVES To systematically review and critically appraise available evidence on the effects of immunonutrition compared to standard non-immunonutrition formula feeding on mechanically ventilated adults (aged 18 years or older) with acute respiratory distress syndrome (ARDS). SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, conference proceedings, and trial registries for appropriate studies up to 25 April 2018. We checked the references from published studies and reviews on this topic for potentially eligible studies. SELECTION CRITERIA We included all randomized controlled trials (RCTs) and quasi-randomized controlled trials comparing immunonutrition versus a control or placebo nutritional formula in adults (aged 18 years or older) with ARDS, as defined by the Berlin definition of ARDS or, for older studies, by the American-European Consensus Criteria for both ARDS and acute lung injury. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of studies and extracted data from the included trials. We sought additional information from study authors. We performed statistical analysis according to Cochrane methodological standards. Our primary outcome was all-cause mortality. Secondary outcomes included intensive care unit (ICU) length of stay, ventilator days, indices of oxygenation, cardiac adverse events, gastrointestinal adverse events, and total number of adverse events. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We identified 10 randomized controlled trials with 1015 participants. All studies compared an enteral formula or additional supplemental omega-3 fatty acids (i.e. eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)), gamma-linolenic acid (GLA), and antioxidants. We assessed some of the included studies as having high risk of bias due to methodological shortcomings. Studies were heterogenous in nature and varied in several ways, including type and duration of interventions given, calorific targets, and reported outcomes. All studies reported mortality. For the primary outcome, study authors reported no differences in all-cause mortality (longest period reported) with the use of an immunonutrition enteral formula or additional supplements of omega-3 fatty acids and antioxidants (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.59 to 1.07; participants = 1015; studies = 10; low-quality evidence).For secondary outcomes, we are uncertain whether immunonutrition with omega-3 fatty acids and antioxidants reduces ICU length of stay (mean difference (MD) -3.09 days. 95% CI -5.19 to -0.99; participants = 639; studies = 8; very low-quality evidence) and ventilator days (MD -2.24 days, 95% CI -3.77 to -0.71; participants = 581; studies = 7; very low-quality evidence). We are also uncertain whether omega-3 fatty acids and antioxidants improve oxygenation, defined as ratio of partial pressure of arterial oxygen (PaO₂) to fraction of inspired oxygen (FiO₂), at day 4 (MD 39 mmHg, 95% CI 10.75 to 67.02; participants = 676; studies = 8), or whether they increase adverse events such as cardiac events (RR 0.87, 95% CI 0.09 to 8.46; participants = 339; studies = 3; very low-quality evidence), gastrointestinal events (RR 1.11, 95% CI 0.71 to 1.75; participants = 427; studies = 4; very low-quality evidence), or total adverse events (RR 0.91, 95% CI 0.67 to 1.23; participants = 517; studies = 5; very low-quality evidence). AUTHORS' CONCLUSIONS This meta-analysis of 10 studies of varying quality examined effects of omega-3 fatty acids and/or antioxidants in adults with ARDS. This intervention may produce little or no difference in all-cause mortality between groups. We are uncertain whether immunonutrition with omega-3 fatty acids and antioxidants improves the duration of ventilator days and ICU length of stay or oxygenation at day 4 due to the very low quality of evidence. Adverse events associated with immunonutrition are also uncertain, as confidence intervals include the potential for increased cardiac, gastrointestinal, and total adverse events.
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Affiliation(s)
- Ahilanandan Dushianthan
- University Hospital Southampton NHS Foundation TrustGeneral Intensive Care UnitTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Rebecca Cusack
- University of SouthamptonIntegrative Physiology and Critical Illness GroupTremona RoadSouthamptonUKSO16 6YD
| | - Victoria A Burgess
- University Hospital Southampton NHS Foundation TrustDepartment of AnaestheticsTremona RoadSouthamptonUKSO16 6YD
| | - Michael PW Grocott
- Faculty of Medicine, University of SouthamptonCritical Care Group, Clinical and Experimental SciencesTremona RoadSouthamptonHampshireUKSO16 6YD
| | - Philip C Calder
- University of SouthamptonHuman Development and Health Academic Unit, Faculty of MedicineMP887 IDS Building, Southampton General HospitalTremona RoadSouthamptonUKSO16 6YD
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McCarthy MS, Martindale RG. Immunonutrition in Critical Illness: What Is the Role? Nutr Clin Pract 2019; 33:348-358. [PMID: 29878555 DOI: 10.1002/ncp.10102] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute illness-associated malnutrition leads to muscle wasting, delayed wound healing, failure to wean from ventilator support, and possibly higher rates of infection and longer hospital stays unless appropriate metabolic support is provided in the form of nutrition therapy. Agreement is still lacking about the value of individual immune-modulating substrates for specific patient populations. However, it has long been agreed that there are 3 primary targets for these substrates: 1) mucosal barrier function, 2) cellular defense function, and 3) local and systemic inflammation. These targets guide the multitude of interventions necessary to stabilize and treat the hypercatabolic intensive care unit patient, including specialized nutrition therapy. The paradigm shift that occurred 30 years ago created a unique role for nutrition as an agent to support host defense mechanisms and prevent infectious complications in the critically ill patient. This overview of immunonutrition will discuss the evidence for its role in critical illness today.
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Affiliation(s)
- Mary S McCarthy
- Center for Nursing Science and Clinical Inquiry, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
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Shariatpanahi ZV, Eslamian G, Ardehali SH, Baghestani AR. Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients. Indian J Crit Care Med 2019; 23:356-362. [PMID: 31485104 PMCID: PMC6709840 DOI: 10.5005/jp-journals-10071-23218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background and aims Enteral administration of glutamine has been proposed as an effective recovery of intestinal barrier function. This amino acid has a modulating effect on the reducing bacterial translocation, which can influence immune functions of the intestine. The objective was to evaluate the effects of early enteral glutamine supplementation on intestinal permeability in critically ill patients. Materials and methods A total of 80 critically ill patients older than 18 years were randomly assigned to one of two groups according to the stratified blocked randomization by age and admission category. Consecutive participants took enteral formula plus 0.3 g/kg/day glutamine powder or enteral formula plus maltodextrin during the ICU stay for a maximum of 10 days. Plasma glutamine, endotoxin, zonulin, and antiendotoxin immunoglobulin (Ig)G/IgM concentrations were measured on days 5 and 10 of intervention. Results Out of 80 participants, 36 patients in the glutamine group and 34 patients in the control group were included in the analysis of the outcomes. Enteral glutamine significantly reduced plasma zonulin concentration up to 40% during 10 days. This reduction was significantly greater compared with that of the placebo group (p<0.001). Endotoxin concentration decreased in both groups; this reduction was significantly greater in the glutamine group (p = 0.014). The antiendotoxin IgM and IgG antibody levels increased in the glutamine group but decreased in the control group (p <0.001). There were no significant differences in clinical outcomes between two groups. Conclusion Early enteral glutamine supplementation led to a declined intestinal permeability in critically ill patients. How to cite this article Shariatpanahi ZV, Eslamian G, Ardehali SH, Baghestani AR. Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients. Indian J Crit Care Med 2019;23(8):356-362.
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Affiliation(s)
- Zahra Vahdat Shariatpanahi
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghazaleh Eslamian
- Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Ardehali
- Department of Anesthesiology and Critical Care, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad-Reza Baghestani
- Department of Biostatistics, Physiotherapy Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abe T, Hosoi T, Kawai R, Uemura N, Higaki E, An B, Kawakami J, Saito T, Shimizu Y. Perioperative enteral supplementation with glutamine, fiber, and oligosaccharide reduces early postoperative surgical stress following esophagectomy for esophageal cancer. Esophagus 2019; 16:63-70. [PMID: 30030739 DOI: 10.1007/s10388-018-0630-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND We clarified the effects of perioperative enteral supplementation with glutamine, fiber, and oligosaccharide (GFO) after an esophagectomy on preventing surgical stress. METHODS Of 326 patients with esophageal cancer, 189 received GFO administration (GFO group) and 137 did not (control group). The propensity score matching method was used to identify 89 well-balanced pairs of patients to compare postoperative laboratory parameters and clinical and postoperative outcomes. RESULTS The duration of the systemic inflammatory response syndrome (SIRS) was significantly shorter in the GFO group compared to the control group (p = 0.002). Moreover, the lymphocyte/neutrophil ratio (L/N ratio) had significantly recovered in the GFO group on postoperative day-3, and the CRP value was significantly lower in the GFO group than that in the control group on postoperative day-2. CONCLUSIONS Perioperative use of enteral supplementation with glutamine, fiber, and oligosaccharide likely contributes to a reduction in early surgical stress after an esophagectomy. These beneficial effects can bring about early recovery from postoperative immunosuppressive conditions after radical esophagectomy.
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Affiliation(s)
- Tetsuya Abe
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan.
| | - Takahiro Hosoi
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Ryosuke Kawai
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Norihisa Uemura
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Eiji Higaki
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Byonggu An
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Jiro Kawakami
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Takuya Saito
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1284] [Impact Index Per Article: 214.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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Culp-Hill R, Srinivasan AJ, Gehrke S, Kamyszek R, Ansari A, Shah N, Welsby I, D'Alessandro A. Effects of red blood cell (RBC) transfusion on sickle cell disease recipient plasma and RBC metabolism. Transfusion 2018; 58:2797-2806. [PMID: 30265764 DOI: 10.1111/trf.14931] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Exchange transfusion is a mainstay in the treatment of sickle cell anemia. Transfusion recipients with sickle cell disease (SCD) can be transfused over 10 units per therapy, an intervention that replaces circulating sickle red blood cells (RBCs) with donor RBCs. Storage of RBCs makes the intervention logistically feasible. The average storage duration for units transfused at the Duke University Medical Center is approximately 2 weeks, a time window that should anticipate the accumulation of irreversible storage lesion to the RBCs. However, no metabolomics study has been performed to date to investigate the impact of exchange transfusion on recipients' plasma and RBC phenotypes. STUDY DESIGN AND METHODS Plasma and RBCs were collected from patients with sickle cell anemia before transfusion and within 5 hours after exchange transfusion with up to 11 units, prior to metabolomics analyses. RESULTS Exchange transfusion significantly decreased plasma levels of markers of systemic hypoxemia like lactate, succinate, sphingosine 1-phosphate, and 2-hydroxyglutarate. These metabolites accumulated in transfused RBCs, suggesting that RBCs may act as scavenger/reservoirs. Transfused RBCs displayed higher glycolysis, total adenylate pools, and 2,3-diphosphoglycerate, consistent with increased capacity to deliver oxygen. Plasma levels of acyl-carnitines and amino acids decreased, while fatty acids and potentially harmful phthalates increased upon exchange transfusion. CONCLUSION Metabolic phenotypes confirm the benefits of the transfusion therapy in transfusion recipients with SCD and the reversibility of some of the metabolic storage lesion upon transfusion in vivo in 2-week-old RBCs. However, results also suggest that potentially harmful plasticizers are transfused.
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Affiliation(s)
- Rachel Culp-Hill
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver-Anschutz Medical Campus, Aurora, Colorado
| | | | - Sarah Gehrke
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver-Anschutz Medical Campus, Aurora, Colorado
| | - Reed Kamyszek
- Duke University Medical Center, Durham, North Carolina
| | - Andrea Ansari
- Duke University Medical Center, Durham, North Carolina
| | - Nirmish Shah
- Duke University Medical Center, Durham, North Carolina
| | - Ian Welsby
- Duke University Medical Center, Durham, North Carolina
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver-Anschutz Medical Campus, Aurora, Colorado
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Tadlock MD, Hannon M, Davis K, Lancman M, Pamplin J, Shackelford S, Martin M, Stockinger Z. Nutritional Support Using Enteral and Parenteral Methods. Mil Med 2018; 183:153-160. [PMID: 30189073 DOI: 10.1093/milmed/usy074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Indexed: 11/14/2022] Open
Abstract
The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.
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Affiliation(s)
- Matthew D Tadlock
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Hannon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Konrad Davis
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Micah Lancman
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeremy Pamplin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Stacy Shackelford
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Martin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Druml W. [Intestinal cross-talk : The gut as motor of multiple organ failure]. Med Klin Intensivmed Notfmed 2018; 113:470-477. [PMID: 30120495 DOI: 10.1007/s00063-018-0475-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 12/31/2022]
Abstract
The central role of the organ system "gut" for critically ill patients has not been acknowledged until the last decade. The gut is a crucial immunologic, metabolic and neurologic organ system and impairment of its functions is associated with morbidity and mortality. The gut has a central position in the cross-talk between organs and dysfunction of the gut may result in impairment of other intra-abdominal and extra-abdominal organ systems. The intestinal tract is the most important source of endogenous infections and determines the inflammatory status of the organism. Gut failure is an element of the multiple organ dysfunction syndrome (MODS). The leading mechanism in the evolution of endogenous infections is the intestinal translocation of microbes. A dysbiosis and damage of the intestinal mucosa leads to a disorder of the mucosal barrier function, increases the permeability and promotes translocation (leaky gut hypothesis). A further crucial mechanism of organ interactions is the increase in intra-abdominal pressure. Intra-abdominal hypertension promotes further injury of the gut, increases translocation and inflammation and causes dysfunction of other organ systems, such as the kidneys, the cardiovascular system and the lungs. Maintaining and/or restoring intestinal functions must be a priority of any intensive care therapy. The most important measure is early enteral nutrition. Other measures are the preservation of motility and modulation of the intestinal microbiome. Intra-abdominal hypertension must be reduced by an individually adapted infusion therapy, positioning of the patient, administration of drugs (abdominal compliance) and decompression (by tubes, endoscopically or in severe cases surgically).
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Affiliation(s)
- W Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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