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Bear DE, Summers MJ, Chapple LAS. Dietary protein in the ICU in relation to health outcomes. Curr Opin Clin Nutr Metab Care 2024:00075197-990000000-00168. [PMID: 39150402 DOI: 10.1097/mco.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Critical care nutrition guidelines recommend provision of higher protein doses than recommended in health. These recommendations have been predominately based on lower quality evidence and physiological rationale that greater protein doses may attenuate the significant muscle loss observed in critically ill patients. This review discusses the mechanistic action of protein in the critically ill, details results from recent trials on health outcomes, discusses considerations for interpretation of trial results, and provides an overview of future directions. RECENT FINDINGS Two recent large clinical trials have investigated different protein doses and the effect on clinical outcome. Important findings revealed potential harm in certain sub-groups of patients. This harm must be balanced with the potential for beneficial effects on muscle mass and physical function given that two recent systematic reviews with meta-analyses demonstrated attenuation of muscle loss with higher protein doses. Utilizing biological markers such as urea: creatinine ratio or urea levels may prove useful in monitoring harm from higher protein doses. SUMMARY Future research should focus on prospectively investigating biological signatures of harm as well as taking into the consideration elements that will likely enhance the effectiveness of protein dose.
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Affiliation(s)
- Danielle E Bear
- Department of Nutrition and Dietetics
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust
- Department of Nutritional Sciences, King's College London, London, UK
| | - Matthew J Summers
- Intensive Care Research, Royal Adelaide Hospital
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
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2
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Chichra A, Tickoo M, Honiden S. Managing the Chronically Ventilated Critically Ill Population. J Intensive Care Med 2024; 39:703-714. [PMID: 37787184 DOI: 10.1177/08850666231203601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
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Affiliation(s)
- Astha Chichra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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3
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Sun JK, Lv C, Gao L, Mao W, Li W, Ke L. Nutrition therapy in critically ill patients with severe acute pancreatitis. Nutr Clin Pract 2024; 39:271-280. [PMID: 38357829 DOI: 10.1002/ncp.11135] [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: 09/29/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Abstract
A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.
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Affiliation(s)
- Jia-Kui Sun
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Cheng Lv
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Lin Gao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
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van Gassel RJ, Weijzen ME, Kouw IW, Senden JM, Wodzig WK, Olde Damink SW, van de Poll MC, van Loon LJ. Administration of Free Amino Acids Improves Exogenous Amino Acid Availability when Compared with Intact Protein in Critically Ill Patients: A Randomized Controlled Study. J Nutr 2024; 154:554-564. [PMID: 38103646 DOI: 10.1016/j.tjnut.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/24/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Protein digestion and amino acid absorption appear compromised in critical illness. The provision of enteral feeds with free amino acids rather than intact protein may improve postprandial amino acid availability. OBJECTIVE Our objective was to quantify the uptake of diet-derived phenylalanine after the enteral administration of intact protein compared with an equivalent amount of free amino acids in critically ill patients. METHODS Sixteen patients who were mechanically ventilated in intensive care unit (ICU) at risk of malabsorption received a primed continuous infusion of L-[ring-2H5]-phenylalanine and L-[ring-3,5-2H2]-tyrosine after an overnight fast. Patients were randomly allocated to receive 20 g intrinsically L-[1-13C]-phenylalanine-labeled milk protein or an equivalent amount of amino acids labeled with free L-[1-13C]-phenylalanine via a nasogastric tube over a 2-h period. Protein digestion and amino acid absorption kinetics and whole-body protein net balance were assessed throughout a 6-h period. RESULTS After enteral nutrient infusion, both plasma phenylalanine and leucine concentrations increased (P-time < 0.001), with a more rapid and greater rise after free amino acid compared with intact protein administration (P-time × treatment = 0.003). Diet-derived phenylalanine released into the circulation was 25% greater after free amino acids compared with intact protein administration [68.7% (confidence interval {CI}: 62.3, 75.1%) compared with 43.8% (CI: 32.4, 55.2%), respectively; P < 0.001]. Whole-body protein net balance became positive after nutrient administration (P-time < 0.001) and tended to be more positive after free amino acid in provision (P-time × treatment = 0.07). CONCLUSIONS The administration of free amino acids as opposed to intact protein further increases postprandial plasma amino acid availability in critically ill patients, allowing more diet-derived phenylalanine to become available to peripheral tissues. This trial was registered at clinicaltrials.gov as NCT04791774.
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Affiliation(s)
- Rob Jj van Gassel
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of Intensive Care Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands.
| | - Michelle Eg Weijzen
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Imre Wk Kouw
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Joan Mg Senden
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Will Khw Wodzig
- Central Diagnostic Laboratory, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Steven Wm Olde Damink
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of General, Visceral- and Transplantation Surgery, RWTH Aachen University, Aachen, Germany
| | - Marcel Cg van de Poll
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands; Department of Intensive Care Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Luc Jc van Loon
- Department of Human Biology, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre +, Maastricht, The Netherlands
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5
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Schneider S, Hartmann K, Dörfelt R. Influence of intravenous 10% amino acids infusion on serum albumin concentration in hypoalbuminemic dogs. Front Vet Sci 2023; 10:1198534. [PMID: 37342623 PMCID: PMC10277565 DOI: 10.3389/fvets.2023.1198534] [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: 04/01/2023] [Accepted: 05/18/2023] [Indexed: 06/23/2023] Open
Abstract
Objective To evaluate the effect of parenteral amino acid application in hospitalized hypoalbuminemic dogs. Materials and methods Medical records of client-owned hypoalbuminemic dogs (albumin ≤ 25 g/L) were analyzed. Dogs receiving amino acids for only 1-2 days, receiving transfusions or surgery, or <6 months of age were excluded. Dogs were grouped as those receiving intravenous amino acids (AA, 80 dogs) over 3 days and longer, and those without additional amino acid treatment (CON, 78 dogs). Duration of hospitalization, albumin, and total protein concentrations were compared between groups by Mann-Whitney U test. Course of albumin and total protein concentration was evaluated by Friedman test and Dunn's multiple comparison test. Significance was set to p ≤ 0.05. Results Dogs in group AA received 10% amino acid solution intravenously over median 4 days (3-11 days). No significant differences regarding survival and adverse effects were observed between groups. Dogs of group AA had significantly longer duration of hospitalization (median 8 days; 3-33 days) compared to group CON dogs (median 6 days, 3-24 days; p < 0.001). Initial albumin concentration was lower in group AA compared to CON (p < 0.001). This difference was no longer present on day 2 (p = 0.134). Conclusions and clinical relevance Intravenous application of 10% amino acid solution in hypoalbuminemic dogs can improve albumin concentration after 2 days, but does not influence outcome.
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Chapple LAS, Kouw IWK, Summers MJ, Weinel LM, Gluck S, Raith E, Slobodian P, Soenen S, Deane AM, van Loon LJC, Chapman MJ. Muscle Protein Synthesis Following Protein Administration in Critical Illness. Am J Respir Crit Care Med 2022; 206:740-749. [PMID: 35584344 DOI: 10.1164/rccm.202112-2780oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.
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Affiliation(s)
- Lee-Anne S Chapple
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia;
| | - Imre W K Kouw
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Maastricht University Medical Centre+, 199236, Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, Limburg, Netherlands
| | - Matthew J Summers
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Samuel Gluck
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Eamon Raith
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Peter Slobodian
- Central Adelaide Local Health Network, 375072, Pharmacy, Adelaide, South Australia, Australia
| | - Stijn Soenen
- The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Bond University Faculty of Health Sciences and Medicine, 104559, Gold Coast, Queensland, Australia
| | - Adam M Deane
- The University of Melbourne, 2281, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia
| | - Luc J C van Loon
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Department of Human Biology, Maastricht, Netherlands
| | - Marianne J Chapman
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
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7
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Chapek MA, Martindale RG. Nutrition in Cancer Therapy: Overview for the Cancer Patient. JPEN J Parenter Enteral Nutr 2021; 45:33-40. [PMID: 34459006 DOI: 10.1002/jpen.2259] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/18/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022]
Abstract
Despite significant advances in oncologic treatment, cancer-associated metabolic derangements remain largely poorly understood and often neglected in cancer care. Cancer cachexia and metabolic changes exhibited by neoplastic cells pose formidable barriers to improving outcomes and quality of life. Although cancer has traditionally been viewed as a proliferative disease caused by genetic mutations, newer perspectives suggest that it is primarily a metabolic disease. This paper discusses the etiology of cachexia and sarcopenia, and nutritional interventions that can address these wasting disorders. The role of inflammation in cancer and the methods for preventing and resolving inflammation with nutrition intervention are also explored. Several nutritional recommendations aimed at overcoming cachexia, resolving inflammation and improving cancer outcomes are provided based on current literature. This manuscript selected only a few areas in which to focus and is not all inclusive of the expansive literature available on the topic of cachexia. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Robert G Martindale
- Professor of Surgery, Division of GI and General Surgery, Oregon Health Sciences University, Portland, Oregon, United States
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Albert BD, Spolidoro GC, Mehta NM. Metabolism and energy prescription in critically III children. Minerva Anestesiol 2021; 87:1025-1033. [PMID: 33853268 DOI: 10.23736/s0375-9393.21.14825-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Optimal nutrition therapy can positively influence clinical outcomes in critically ill children. Accurate assessment of nutritional status, metabolic state, macronutrient requirements and substrate utilization allows accurate prescription of nutrition in this population. In response to stress and injury, the body undergoes adaptive physiologic changes leading to dysregulation of the inflammatory response and hyperactivation of the inflammatory cascade. This results in a global catabolic state with modification in oxygen consumption and macronutrient metabolism. A comprehensive understanding of the metabolic response is essential when prescribing nutritional interventions aimed to offset the burden of this adaptive stress response in the critically ill. In this narrative review we aim to provide a comprehensive review of the physiologic basis, recent literature and some emerging concepts related to energy expenditure and the practical aspects of energy delivery in the critically ill child. Based on the unique metabolic characteristics of the critically ill child, we aim to provide a pragmatic approach to providing nutrition therapy.
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Affiliation(s)
- Ben D Albert
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Cambridge, MA, USA
| | - Giulia C Spolidoro
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA - .,Harvard Medical School, Cambridge, MA, USA.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Center for Nutrition, Boston Children's Hospital, Boston, MA, USA
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9
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Chapple LAS, Dirks ML, Kouw IW. Stable isotope approaches to study muscle mass outcomes in clinical populations. CLINICAL NUTRITION OPEN SCIENCE 2021. [DOI: 10.1016/j.nutos.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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10
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van Gassel RJJ, van de Poll MCG, Schaap FG, Plummer M, Deane A, Olde Damink SWM. Postprandial rise of essential amino acids is impaired during critical illness and unrelated to small-intestinal function. JPEN J Parenter Enteral Nutr 2021; 46:114-122. [PMID: 33666262 PMCID: PMC9293041 DOI: 10.1002/jpen.2103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Postprandial rise of plasma essential amino acids (EAAs) determines the anabolic effect of dietary protein. Disturbed gastrointestinal function could impair the anabolic response in critically ill patients. Aim was to investigate the postprandial EAA response in critically ill patients and its relation to small‐intestinal function. Methods Twenty‐one mechanically ventilated patients and 9 healthy controls received a bolus containing 100 ml of a formula feed (Ensure) and 2 g of 3‐O‐Methyl‐d‐glucose (3‐OMG) via postpyloric feeding tube. Fasting and postprandial plasma concentrations of EAAs, 3‐OMG, total bile salts, and the gut‐released hormone fibroblast growth factor 19 (FGF19) were measured over a 4‐hour period. Changes over time and between groups were assessed with linear mixed‐effects analysis. Early (0–60 minutes) and total postprandial responses are summarized as the incremental area under the curve (iAUC). Results At baseline, fasting EAA levels were similar in both groups: 1181 (1055–1276) vs 1150 (1065–1334) μmol·L−1, P = .87. The early postprandial rise in EAA was not apparent in critically ill patients compared with healthy controls (iAUC60, −4858 [−6859 to 2886] vs 5406 [3099–16,853] µmol·L−1·60 minutes; P = .039). Impaired EAA response did not correlate with impaired 3‐OMG response (Spearman ρ 0.32, P = .09). There was a limited increase in total bile salts but no relevant FGF19 response in either group. Conclusion Postprandial rise of EAA is blunted in critically ill patients and unrelated to glucose absorption measured with 3‐OMG. Future studies should aim to delineate governing mechanisms of macronutrient malabsorption.
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Affiliation(s)
- Rob J J van Gassel
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - Marcel C G van de Poll
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - Frank G Schaap
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Mark Plummer
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam Deane
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
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11
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Duan K, Gao X, Wei L, Gong M, Feng B, Zhou J, Zhu D. Skeletal muscle depletion and nutrition support affected postoperative complications in patients who underwent pancreatoduodenectomy. Eur J Clin Nutr 2021; 75:1218-1226. [PMID: 33483631 DOI: 10.1038/s41430-020-00851-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Body composition has been shown closely related to the outcome in surgical patients. The aim of the present study was to investigate whether preoperative skeletal muscle condition and postoperative nutrition would affect major complications in patients underwent pancreaticoduodenectomy (PD). METHODS This retrospective study included 265 patients underwent PD. Body composition data was extracted from the L3 level of the preoperative CT scan. Univariable and multivariable regression analyses were performed to investigate correlations between body composition data and postoperative complications. Furthermore, a subgroup analysis was conducted to explore the relationship between postoperative nutrition strategy and the outcome. RESULTS Of all the 265 patients, major complications occurred in 81 patients (30.6%). Cutoff values for skeletal muscle depletion were defined by ROC curve analysis from postoperative complications in skeletal muscle index (SMI) (male 47.32 cm2/m2 and female 40.65 cm2/m2). Univariable analysis and multivariable regression revealed age (OR 1.49, 95% CI 1.22-1.83, p = 0.026), SMI (OR 0.77, 95% CI 0.51-0.94, p = 0.015) and skeletal muscle density (SMD) (OR 0.85, 95% CI 0.64-1.03, p = 0.029) were independent predictors for major complications. Subgroup analysis showed the initial parenteral nutrition time (IPNT) (OR 1.89, 95% CI 1.43-2.49, p = 0.032) and average protein delivery (APD) (OR 0.76, 95% CI 0.53-0.89, p = 0.021) were significantly associated with major complications in patients with lower SMI. CONCLUSIONS Preoperative skeletal muscle index and density were independently associated with major complications in patients underwent PD. In patients with lower SMI, early parenteral nutrition and higher protein delivery were related to better outcome.
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Affiliation(s)
- Kaipeng Duan
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Xin Gao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Luxin Wei
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Mengting Gong
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Bin Feng
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Jin Zhou
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China.
| | - Dongming Zhu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China.
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12
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Abstract
PURPOSE OF REVIEW Timing, dose, and route of protein feeding in critically ill patients treated in an ICU is controversial. This is because of conflicting outcomes observed in randomized controlled trials (RCTs). This inconsistency between RCTs may occur as the physiology of protein metabolism and protein handling in the critically ill is substantially different from the healthy with limited mechanistic data to inform design of RCTs. This review will outline the current knowledge and gaps in the understanding of protein absorption and kinetics during critical illness. RECENT FINDINGS Critically ill patients, both children and adults, lose muscle protein because of substantial increases in protein degradation with initially normal, and over time increasing, protein synthesis rates. Critically ill patients appear to retain the capacity to absorb dietary protein and to use it for building body protein; however, the extent and possible benefit of this needs to be elucidated. More sophisticated methods to study protein absorption and digestion have recently been described but these have yet to be used in the critically ill. SUMMARY Adequate understanding of protein absorption and kinetics during critical illness will help the design of better interventional studies in the future. Because of the complexity of measuring protein absorption and kinetics in the critically ill, very few investigations are executed. Recent data using isotope-labelled amino acids suggests that critically ill patients are able to absorb enteral protein and to synthesize new body protein. However, the magnitude of absorption and anabolism that occurs, and possible benefits for the patients need to be elucidated.
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Affiliation(s)
- Felix Liebau
- Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Division of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Huddinge, Sweden
| | - Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Olav Rooyackers
- Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Division of Anesthesiology and Intensive Care, CLINTEC, Karolinska Institutet, Huddinge, Sweden
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13
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Sundström Rehal M, Liebau F, Wernerman J, Rooyackers O. Whole-body protein kinetics in critically ill patients during 50 or 100% energy provision by enteral nutrition: A randomized cross-over study. PLoS One 2020; 15:e0240045. [PMID: 33017434 PMCID: PMC7535026 DOI: 10.1371/journal.pone.0240045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/16/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) is a ubiquitous intervention in ICU patients but there is uncertainty regarding the optimal dose, timing and importance for patient-centered outcomes during critical illness. Our research group has previously found an improved protein balance during normocaloric versus hypocaloric parenteral nutrition in neurosurgical ICU patients. We now wanted to investigate if this could be demonstrated in a general ICU population with established enteral feeding, including patients on renal replacement therapy. METHODS Patients with EN >80% of energy target as determined by indirect calorimetry were randomized to or 50% or 100% of current EN rate. After 24 hours, whole-body protein kinetics were determined by enteral and parenteral stable isotope tracer infusions. Treatment allocation was then switched, and tracer investigations repeated 24 hours later in a crossover design with patients serving as their own controls. RESULTS Six patients completed the full protocol. During feeding with 100% EN all patients received >1.2 g/kg/day of protein. Mean whole-body protein balance increased from -6.07 to 2.93 µmol phenylalanine/kg/h during 100% EN as compared to 50% (p = 0.044). The oxidation rate of phenylalanine was unaltered (p = 0.78). CONCLUSIONS It is possible to assess whole-body protein turnover using a stable isotope technique in critically ill patients during enteral feeding and renal replacement therapy. Our results also suggest a better whole-body protein balance during full dose as compared to half dose EN. As the sample size was smaller than anticipated, this finding should be confirmed in larger studies.
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Affiliation(s)
- Martin Sundström Rehal
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Felix Liebau
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Duan K, Gao X, Zhu D. The clinical relevance and mechanism of skeletal muscle wasting. Clin Nutr 2020; 40:27-37. [PMID: 32788088 DOI: 10.1016/j.clnu.2020.07.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/15/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023]
Abstract
Skeletal muscle wasting occurs in both chronic and acute diseases. Increasing evidence has shown this debilitating process is associated with short- and long-term outcomes in critical, cancer and surgical patients. Both muscle quantity and quality, as reflected by the area and density of a given range of attenuation in CT scan, impact the patient prognosis. In addition, ultrasound and bioelectrical impedance analysis (BIA) are also widely used in the assessment of body composition due to their bedside viability and no radioactivity. Mechanism researches have revealed complicated pathways are involved in muscle wasting, which include altered IGF1-Akt-FoxO signaling, elevated levels of myostatin and activin A, activation of NF-κB pathway and glucocorticoid effects. Particularly, central nervous system (CNS) has been proven to participate in regulating muscle wasting in various conditions, such as infection and tumor. Several promising therapeutic agents have been under developing in the treatment of muscle atrophy, such as myostatin antagonist, ghrelin analog, non-steroidal selective androgen receptor modulators (SARMs). Notably, nutritional therapy is still the fundamental support in combating muscle wasting. However, the optimizing and tailored nutrition regimen relies on accurate metabolism measurement and large clinical trials in the future. Here, we will discuss the current understanding of muscle wasting and potential treatment in clinical practice.
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Affiliation(s)
- Kaipeng Duan
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China
| | - Xin Gao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China
| | - Dongming Zhu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, PR China.
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15
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Translating the European Society for Clinical Nutrition and Metabolism 2019 guidelines into practice. Curr Opin Crit Care 2020; 25:314-321. [PMID: 31107309 DOI: 10.1097/mcc.0000000000000619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To present a pragmatic approach to facilitate clinician's implementing the recent European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on clinical nutrition in the intensive care unit. RECENT FINDINGS The ESPEN guidelines include 54 recommendations with a rationale for each recommendation. All data published since 1 January 2000 was reviewed and 31 meta-analyses were performed to inform these guidelines. An important aspect of the most recent ESPEN guidelines is an attempt to separate periods of critical illness into discrete - early acute, late acute and recovery - phases, with each exhibiting different metabolic profiles and requiring different strategies for nutritional and metabolic support. SUMMARY A pragmatic approach to incorporate the recent ESPEN guidelines into everyday clinical practice is provided.
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16
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Leyderman I, Yaroshetskiy A, Klek S. Protein Requirements in Critical Illness: Do We Really Know Why to Give So Much? JPEN J Parenter Enteral Nutr 2020; 44:589-598. [PMID: 32043628 DOI: 10.1002/jpen.1792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 12/27/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
The protein and energy requirements of critically ill patients treated in intensive care units (ICUs) have been actively discussed recently. Currently published clinical recommendations and reviews suggest significant increases of protein provision to 2-2.5 g/kg/d in some populations of ICU patients. However, a detailed analysis of the main sources of these recommendations reveals a number of serious contradictions, as well as an absence of obvious evidence supporting the allotment of high doses of protein. We went through these recommendations and reviewed cited articles and other studies, and we have separated our arguments against excessive protein provision into sections.
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Affiliation(s)
- Ilya Leyderman
- Intensive Care Unit, Ural State Medical University, Yekaterinburg, Russia
| | - Andrey Yaroshetskiy
- Vorokhobov Municipal Clinical Hospital No. 67, Intensive Care Unit, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Stanislaw Klek
- General Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
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17
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Abstract
PURPOSE OF REVIEW The objective of this review is to describe the impact of protein intake on the outcomes of critically ill patients in the literature published in the preceding 2 years. RECENT FINDINGS Observational studies showed inconsistent results regarding the association of higher protein intake and outcomes of critically ill patients. Randomized controlled trials that directly compared higher versus lower protein intake in ICU patients are scarce, varied considerably in their designs and primary outcomes, and generally had relatively small differences in the amount of delivered protein between the study arms. Systematic reviews of existing studies showed no difference in mortality with higher protein intake. In addition, there is uncertainty regarding high protein provision in the early phase of critical illness. SUMMARY The optimal amount of protein intake in critically ill patients remains largely unclear and is considered a high priority for research. Ongoing clinical trials are likely to provide additional evidence on several important questions including the dose, timing, type of protein and the interaction with caloric intake and exercise.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard - Health Affairs King Abdullah International Medical Research Center College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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18
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Influence of Early versus Late supplemental ParenteraL Nutrition on long-term quality of life in ICU patients after gastrointestinal oncological surgery (hELPLiNe): study protocol for a randomized controlled trial. Trials 2019; 20:777. [PMID: 31881984 PMCID: PMC6935061 DOI: 10.1186/s13063-019-3796-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 10/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Nutrition plays a major role in intensive care unit (ICU) treatment, influencing ICU length of stay and patient’s survival. If preferable enteral nutrition administration is not feasible, ESPEN and ASPEN guidelines recommend initiation of a supplemental parenteral route between the first and seventh day, but exact timing remains elusive. While rapid development in critical care enabled significant reduction in the mortality rate of ICU patients, this improvement also tripled the number of patients going to rehabilitation. Thus, it is quality of life after ICU that has become the subject of interest of clinicians and healthcare policy-makers. A growing body of evidence indicates that protein turnover in the early phase of critical illness may play a crucial role in the preservation of lean body mass. A negative protein balance may lead to muscle wasting that persists weeks and months after ICU stay, resulting in deterioration of physical functioning. Folliwing oncological gastrointestinal tract surgery, patients are threatened with negative protein turnover due to cancer and extensive surgical insult. Methods This is a multi-centre, single-blinded, randomised controlled trial. The study population includes patients admitted to ICU units after major oncological gastrointestinal surgery that require supplemental parenteral nutrition. After initiation of enteral nutrition, the intervention group receives remaining daily requirement via supplemental parenteral nutrition on the first day of ICU stay while the control group is not supplemented parenterally until the seventh day of ICU stay while enteral nutrition is gradually increased. Primary endpoint: long-term quality of life measured in the physical component score (PCS) of SF-36 questionnaire at 3 and 6 months after ICU admission. Discussion To our knowledge, this is the first trial to investigate the influence of early supplemental parenteral nutrition on long-term quality of life after major oncological gastrointestinal surgery. We assume that, particularly in this population of patients, early supplemental parenteral nutrition may increase the long-term quality of life. The study construction also allows establishment of patients’ PCS SF-36 score prior to surgery and mean change in PCS SF-36 score during the recovery period, which is rarely seen in studies on critically ill patients. Trial registration ClinicalTrials.gov: NCT03699371 registered on 12 October 2018.
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19
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Wernerman J, Christopher KB, Annane D, Casaer MP, Coopersmith CM, Deane AM, De Waele E, Elke G, Ichai C, Karvellas CJ, McClave SA, Oudemans-van Straaten HM, Rooyackers O, Stapleton RD, Takala J, van Zanten ARH, Wischmeyer PE, Preiser JC, Vincent JL. Metabolic support in the critically ill: a consensus of 19. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:318. [PMID: 31533772 PMCID: PMC6751850 DOI: 10.1186/s13054-019-2597-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/02/2019] [Indexed: 12/11/2022]
Abstract
Metabolic alterations in the critically ill have been studied for more than a century, but the heterogeneity of the critically ill patient population, the varying duration and severity of the acute phase of illness, and the many confounding factors have hindered progress in the field. These factors may explain why management of metabolic alterations and related conditions in critically ill patients has for many years been guided by recommendations based essentially on expert opinion. Over the last decade, a number of randomized controlled trials have been conducted, providing us with important population-level evidence that refutes several longstanding paradigms. However, between-patient variation means there is still substantial uncertainty when translating population-level evidence to individuals. A cornerstone of metabolic care is nutrition, for which there is a multifold of published guidelines that agree on many issues but disagree on others. Using a series of nine questions, we provide a review of the latest data in this field and a background to promote efforts to address the need for international consistency in recommendations related to the metabolic care of the critically ill patient. Our purpose is not to replace existing guidelines, but to comment on differences and add perspective.
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Affiliation(s)
- Jan Wernerman
- Department of Anaesthesia and Intensive Care Medicine, Karolinska Institutet, 14186, Stockholm, Sweden
| | - Kenneth B Christopher
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Djillali Annane
- General ICU, Hôpital Raymond Poincaré APHP, Garches, France.,School of Medicine Simone Veil, University Paris Saclay - UVSQ, Versailles, France
| | - Michael P Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000, Leuven, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam M Deane
- Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne Medical School, Parkville, VIC, 3050, Australia
| | - Elisabeth De Waele
- ICU Department, Nutrition Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090, Brussels, Belgium
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, 24105, Kiel, Germany
| | - Carole Ichai
- Department of Anesthesiology and Intensive Care Medicine, Adult Intensive Care Unit, Université Côte d'Azur, Nice, France
| | - Constantine J Karvellas
- Division of Gastroenterology and Department of Critical Care Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA
| | | | - Olav Rooyackers
- Anesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Huddinge, Sweden
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine , Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, 6716 RP, Ede, Netherlands
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
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Engelen MPKJ, Ten Have GAM, Thaden JJ, Deutz NEP. New advances in stable tracer methods to assess whole-body protein and amino acid metabolism. Curr Opin Clin Nutr Metab Care 2019; 22:337-346. [PMID: 31192825 DOI: 10.1097/mco.0000000000000583] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Stable isotope methods have been used for many years to assess whole-body protein and amino acid kinetics in healthy conditions and in response to aging, exercise and (clinically stable) disease states. RECENT FINDINGS In recent years, tracer research expanded to the anabolic response to feeding in critical illness and its use during acute metabolic stressors. Furthermore, new isotope approaches and tracer insights have been obtained. In the postabsorptive state, the novel tracer pulse approach has several advantages above the established continuous tracer approach because of the metabolic information that can be obtained, easy applicability, and low tracer costs. The use of bolus versus sip-feeding approaches to assess the anabolic response to a meal is dependent on the research question and its feasibility. Promising new tracer approaches have been developed to measure the anabolic capacity, and protein digestibility and absorption. Advances have been made in the field of mass spectrometry in low enrichment analysis. SUMMARY Novel tracer approaches are available that can more readily be used in critical illness and during acute metabolic stressors. Besides the use of tracer application in various clinical conditions, more research is needed on how to incorporate isotopes on an individual level.
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Affiliation(s)
- Mariëlle P K J Engelen
- Department of Health and Kinesiology, Center for Translational Research in Aging & Longevity, Texas A&M University, College Station, Texas, USA
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21
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Commentary: Acute kidney injury: The one-million-pieces puzzle. J Thorac Cardiovasc Surg 2019; 157:2367-2368. [DOI: 10.1016/j.jtcvs.2018.11.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 02/02/2023]
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Abstract
PURPOSE OF REVIEW Skeletal muscle mass with aging, during critical care, and following critical care is a determinant of quality of life and survival. In this review, we discuss the mechanisms that underpin skeletal muscle atrophy and recommendations to offset skeletal muscle atrophy with aging and during, as well as following, critical care. RECENT FINDINGS Anabolic resistance is responsible, in part, for skeletal muscle atrophy with aging, muscle disuse, and during disease states. Anabolic resistance describes the reduced stimulation of muscle protein synthesis to a given dose of protein/amino acids and contributes to declines in skeletal muscle mass. Physical inactivity induces: anabolic resistance (that is likely exacerbated with aging), insulin resistance, systemic inflammation, decreased satellite cell content, and decreased capillary density. Critical illness results in rapid skeletal muscle atrophy that is a result of both anabolic resistance and enhanced skeletal muscle breakdown. SUMMARY Insofar as atrophic loss of skeletal muscle mass is concerned, anabolic resistance is a principal determinant of age-induced losses and appears to be a contributor to critical illness-induced skeletal muscle atrophy. Older individuals should perform exercise using both heavy and light loads three times per week, ingest at least 1.2 g of protein/kg/day, evenly distribute their meals into protein boluses of 0.40 g/kg, and consume protein within 2 h of retiring for sleep. During critical care, early, frequent, and multimodal physical therapies in combination with early, enteral, hypocaloric energy (∼10-15 kcal/kg/day), and high-protein (>1.2 g/kg/day) provision is recommended.
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Abstract
PURPOSE OF REVIEW Sarcopenic obese in older ICU patients may have a higher risk of poor recovery during and after ICU stay, which may lead to longer hospital stay and poor quality of life. In this review, causes, consequences, and nutrition strategies to combat sarcopenic obesity in the ICU are discussed. RECENT FINDINGS Physical inactivity, inflammation, anabolic resistance, as well as disturbances in hormone levels are, important causes for the strongly accelerated decline in muscle mass and muscle strength in ICU patients. These causes may lead to changes in amino acid metabolism and anabolic resistance. Obese individuals show specific muscle characteristics (e.g. adipose infiltration, lower capillary density) which are associated with impaired functionality. Specific energy and protein intake recommendations are needed to attenuate sarcopenic obesity in ICU patients. SUMMARY Nutrient utilization in sarcopenic obese ICU patients is a complex challenge as many metabolic factors and clinical situations may impact the efficacy of nutritional interventions. Nutritional strategies should consist of high-protein and hypocaloric feeding along with nonprotein sources such as vitamin D, omega-3 fatty acids, or physical activity. There is a great need, however, for randomized controlled trials (RCTs) combining various nutritional strategies with physical activity in sarcopenic obese ICU patients.
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Affiliation(s)
- Michael Tieland
- Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Carliene van Dronkelaar
- Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
| | - Yves Boirie
- Unité de Nutrition Humaine, INRA, CRNH Auvergne, CHU Clermont-Ferrand, Service de Nutrition Clinique, Université Clermont Auvergne, Clermont-Ferrand, France
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Sundström-Rehal M, Tardif N, Rooyackers O. Can exercise and nutrition stimulate muscle protein gain in the ICU patient? Curr Opin Clin Nutr Metab Care 2019; 22:146-151. [PMID: 30585804 DOI: 10.1097/mco.0000000000000548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The intended purpose of nutritional and exercise interventions during ICU stay is often to limit the muscle loss associated with critical illness. Unfortunately, direct measurements of muscle protein turnover or potential surrogates have often been neglected in clinical trials. RECENT FINDINGS We discuss the potential advantages and drawbacks of common outcome measures for assessing changes in muscle structure and function over time, and how temporal changes in patient physiology require consideration. There is an increasing awareness of emphasizing functional outcomes in recent clinical trials. We here summarize the latest research on therapies attempting to limit muscle loss in ICU patients, with a focus on muscle protein metabolism. No recent or older studies show any effect of nutritional interventions on muscle protein gain, although some smaller studies show a promising positive effect on muscle thickness and function. Some studies show a positive effect of increased physical activity in the ICU on muscle mass and function but heterogeneity of the interventions and outcome measures make any general conclusions impossible. SUMMARY Several knowledge gaps remain regarding the importance of muscle protein regulation as a driver of improved physical function following ICU discharge. In our opinion, physiological investigations are needed to guide the design and interpretation of future clinical trials.
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Affiliation(s)
- Martin Sundström-Rehal
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Tardif
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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25
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van Zanten ARH. Response to Gunst and Casaer on the letter to the editor "Is the protein intake saturated at doses recommended by the feeding guidelines for critically ill patients?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:330. [PMID: 30514322 PMCID: PMC6280352 DOI: 10.1186/s13054-018-2189-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/23/2023]
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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27
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Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol 2018; 44:919-926. [DOI: 10.1016/j.ejso.2018.04.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 01/24/2023] Open
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Weijs PJM. Route, early or energy? … Protein improves protein balance in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:91. [PMID: 29653538 PMCID: PMC5899390 DOI: 10.1186/s13054-018-2015-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 03/16/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Peter J M Weijs
- Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands. .,Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands. .,Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Science, Amsterdam, The Netherlands. .,Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands.
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Nutritional Considerations in Preventing Muscle Atrophy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1088:497-528. [DOI: 10.1007/978-981-13-1435-3_23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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