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Chen L, Wang Y. Survival analysis of famotidine administration routes in non-traumatic intracerebral hemorrhage patients: based on the MIMIC-IV database. Expert Rev Pharmacoecon Outcomes Res 2024. [PMID: 39155563 DOI: 10.1080/14737167.2024.2394113] [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: 03/27/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/20/2024]
Abstract
OBJECTIVE This project aims to compare the survival outcomes of non-traumatic intracerebral hemorrhage (ICH) patients with different famotidine administration routes, and explore the risk factors influencing patients' clinical outcomes. METHODS Data of patients admitted to the ICU from 2008 to 2019 and receiving famotidine therapy were collected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients selected for ICU admission > 1 day and treated with famotidine were divided into the group via intravenous (IV) dosing and the group via non-intravenous (Non-IV) dosing. Cox analysis and bilateral stepwise regression were utilized to determine independent prognostic factors affecting patient survival. Survival of patients on different routes of administration before and after propensity score matching (PSM) was compared using Kaplan - Meier (K-M) survival curves. RESULTS This investigation included 351 patients. After PSM was matched with a 1:2 ratio, 109 patients were clustered in the IV group and 84 patients in the Non-IV group. Cox multivariate results uncovered that survival prognosis in ICH patients receiving famotidine was associated with age (HR = 1.031, 95%CI:1.011-1.050, p = 0.002), chloride ion levels (HR = 1.061, 95%CI:1.027-1.096, p < 0.001), blood urea nitrogen (BUN) (HR = 1.034, 95%CI:1.007-1.062, p = 0.012), intracranial pressure (ICP) (HR = 1.059, 95%CI:1.027-1.092, p < 0.001), red blood cell distribution width (RDW) (HR = 1.156, 95%CI:1.030-1.299, p = 0.014), mechanical ventilation (HR = 2.526, 95%CI:1.341-4.760, p = 0.004), antibiotic use (HR = 0.331, 95%CI:0.144-0.759, p = 0.009), and Non-IV route (HR = 0.518, 95%CI:0.283-0.948, p = 0.033). The K-M curve results indicated that the 30-day survival rate of Non-IV group ICH patients was substantially higher than that of IV group patients (before PSM, p = 0.036; after PSM, p = 0.011). In the subgroup analysis of age, ICP, mechanical ventilation, and antibiotic use, there was a great heterogeneity interaction between the administration of famotidine and the 30-day mortality rate (P for interaction < 0.05). The Non-IV route considerably reduced the risk of death in patients with normal ICP (7-15 mmHg) (HR = 0.518, 95%CI:0.283-0.948, p = 0.033). CONCLUSION Among ICH patients receiving famotidine, those receiving famotidine via Non-IV have a better 30-day survival rate compared to those receiving IV, especially in patients with normal ICP (7-15 mmHg).
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Affiliation(s)
- Ling Chen
- Department of Gynaecology, People's Hospital Affiliated to Cangzhou Medical College, Cangzhou, China
| | - Yan Wang
- Department of Basic Medicine, Cangzhou Medical College, Cangzhou, China
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Halim Z, Huang Y, Lee ZY, Lew CCH. New randomized controlled trials on micronutrients in critical care nutrition: A narrative review. Nutr Clin Pract 2024. [PMID: 39119820 DOI: 10.1002/ncp.11195] [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: 11/07/2023] [Revised: 05/14/2024] [Accepted: 07/02/2024] [Indexed: 08/10/2024] Open
Abstract
There has been increasing interest in the role of micronutrient supplementation in critical care. This narrative review summarizes the recent studies on micronutrients in critically ill patients. We searched two databases for primary randomized controlled trials that investigated the effects of micronutrient supplementation in patients with critical illness published from January 2021 to August 2023. Personal files, reference lists of included studies, and previous reviews were also screened. Twelve studies reported on vitamin C, four studies on vitamin D, three studies on thiamin, two studies on multivitamins, and one study on cobalamin. The therapeutic effects of vitamin C appear mixed, although vitamin C monotherapy appears more promising than vitamin C combination therapy. Intramuscular administration of vitamin D appeared to lower mortality, mechanical ventilation duration, and intensive care unit stay, whereas enteral administration showed limited clinical benefits. Intravenous thiamin was not associated with improved outcomes in patients with septic shock or hypophosphatemia. Preliminary evidence suggests reduced vasopressor dose with cobalamin. Decreased disease severity and hospital stay in patients with COVID-19 with vitamins A-E requires further investigation, whereas providing solely B-group vitamins did not demonstrate therapeutic effects. It is currently premature to endorse the provision of high-dose micronutrients in critical illness to improve clinical outcomes. This review may help to inform the design of future trials that will help better elucidate the optimal dosage and form of micronutrients, methods of administration, and subgroups of patients with critical illness who may most benefit.
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Affiliation(s)
- Zakiah Halim
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Yingxiao Huang
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore
- Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
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3
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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [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: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Zolnourian A, Garland P, Holton P, Arora M, Rhodes J, Uff C, Birch T, Howat D, Franklin S, Galea I, Bulters D. A Randomised Controlled Trial of SFX-01 After Subarachnoid Haemorrhage - The SAS Study. Transl Stroke Res 2024:10.1007/s12975-024-01278-1. [PMID: 39028412 DOI: 10.1007/s12975-024-01278-1] [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: 04/26/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Abstract
SFX-01 is a novel drug for clinical delivery of sulforaphane (SFN). SFN is a potent nuclear factor erythroid 2-related factor 2 activator that reduces inflammation and oxidation, improving outcomes after subarachnoid haemorrhage (SAH) in animal models. This was a multi-centre, double-blind, placebo-controlled, parallel-group randomised clinical trial to evaluate the safety, pharmacokinetics and efficacy of 28 days of SFX-01 300 mg BD in patients aged 18-80 with spontaneous SAH and high blood load on CT. Primary outcomes were (1) safety, (2) plasma and CSF SFN and metabolite levels and (3) vasospasm on transcranial doppler ultrasound. Secondary outcomes included CSF haptoglobin and malondialdehyde and clinical outcome on the modified Rankin Scale (mRS) and SAH outcome tool (SAHOT). A total of 105 patients were randomised (54 SFX-01, 51 placebo). There were no differences in adverse events other than nausea (9 SFX-01 (16.7%), 1 placebo (2.0%)). SFN, SFN-glutathione and SFN-N-acetyl-cysteine AUClast were 16.2, 277 and 415 h × ng/ml. Plasma SFN was higher in GSTT1 null individuals (t = 2.40, p = 0.023). CSF levels were low with many samples below the lower limit of quantification and predicted by the CSF/serum albumin ratio (R2 = 0.182, p = 0.039). There was no difference in CSF haptoglobin (1.981 95%CI 0.992-3.786, p = 0.052) or malondialdehyde (1.12 95%CI 0.7477-1.687, p = 0.572) or middle cerebral artery flow velocity (1.04 95%CI 0.903-1.211, p = 0.545) or functional outcome (mRS 1.647 95%CI 0.721-3.821, p = 0.237, SAHOT 1.082 95%CI 0.464-2.525, p = 0.855). SFX-01 is safe and effective for the delivery of SFN in acutely unwell patients. SFN penetrated CSF less than expected and did not reduce large vessel vasospasm or improve outcome. Trial registration: NCT02614742 clinicaltrials.gov.
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Affiliation(s)
| | - Patrick Garland
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Patrick Holton
- Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Mukul Arora
- Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Jonathan Rhodes
- Neuro Intensive Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Tony Birch
- Medical Physics, University Hospital Southampton, Southampton, UK
| | | | | | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Neurology, University Hospital Southampton, Southampton, UK
| | - Diederik Bulters
- Neurosurgery, University Hospital Southampton, Southampton, UK.
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
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Wang L, Zhong X, Yang H, Yang J, Zhang Y, Zou X, Wang L, Zhang Z, Jin X, Kang Y, Wu Q. When can we start early enteral nutrition safely in patients with shock on vasopressors? Clin Nutr ESPEN 2024; 61:28-36. [PMID: 38777444 DOI: 10.1016/j.clnesp.2024.03.007] [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: 09/23/2023] [Revised: 02/17/2024] [Accepted: 03/03/2024] [Indexed: 05/25/2024]
Abstract
Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.
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Affiliation(s)
- Luping Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xia Zou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Lijie Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Ni H, S S, V N, M AR. Effectiveness of Heat Application on Gastric Variables Among Patients With Nasogastric Tube Feeding Admitted in the Intensive Care Units at a Selected Hospital: A Randomized Control Trial. Cureus 2024; 16:e61490. [PMID: 38952591 PMCID: PMC11216127 DOI: 10.7759/cureus.61490] [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: 03/22/2024] [Accepted: 06/01/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Heat application, a nonpharmacological intervention, can relieve abdominal distension (AD), high stomach residual volume, and other specific gastrointestinal (GI) functions. It promotes peristaltic movement, which reduces intra-abdominal pressure and aids in the nutritional transition through the GI tract. It has also been demonstrated to be a noninvasive, safe, effective, and side-effect-free approach without needing medication. OBJECTIVES The objective of the study was to ascertain if heat application may improve stomach residual volume, AD, and GI functioning in patients who were hospitalized in intensive care units (ICUs) and were receiving nasogastric tube feeding. METHODS The study used a quantitative research approach and experimental research design. Subjects were ICU patients hospitalized during data collection who were fed via nasogastric tubes. They were divided into two groups of 30 people each, with one group as the experimental group and the other as the control group. The groups were determined through random sampling using the coverslip method. A selected hospital ICU served as the study's setting. RESULTS Analyses of stomach residual volume, AD, and GI performance revealed a statistically significant improvement in the study group compared to the control group. Research groups experienced significantly fewer vomiting episodes regularly compared to the control group. CONCLUSION In conclusion, all patients receiving nasogastric tube feedings should have local heat application treatment administered as part of their usual nursing care to reduce stomach residual volume, relieve AD, and reduce vomiting.
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Affiliation(s)
- Hilal Ni
- College of Nursing, Muslim Educational Society Academy of Medical Sciences, Perinthalmanna, IND
| | - Santhi S
- Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Nirmala V
- College of Nursing, Muslim Educational Society Academy of Medical Sciences, Perinthalmanna, IND
| | - Anitha Rani M
- Community Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Farbu BH, Lydersen S, Mohus RM, Ueland T, Mollnes TE, Klepstad P, Langeland H. The detrimental effects of intestinal injury mediated by inflammation are limited in cardiac arrest patients: A prospective cohort study. Resusc Plus 2024; 18:100639. [PMID: 38666252 PMCID: PMC11043872 DOI: 10.1016/j.resplu.2024.100639] [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: 02/12/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background Ischaemic intestines could be a driver of critical illness through an inflammatory response. We have previously published reports on a biomarker for intestinal injury, plasma Intestinal Fatty Acid Binding Protein (IFABP), and inflammatory biomarkers after out-of-hospital cardiac arrest (OHCA). In this post-hoc study we explored the potential indirect effects of intestinal injury mediated through the inflammatory response on organ dysfunction and mortality. Methods We measured IFABP and twenty-one inflammatory biomarkers in 50 patients at admission to intensive care unit after OHCA. First, we stratified patients on median IFABP and compared biomarkers between "low" and "high" IFABP. Second, by causal mediation analysis, we assessed effects of IFABP through the two most important inflammatory biomarkers, interleukin (IL)-6 and terminal complement complex (TCC), on day two circulatory variables, Sequential Organ Failure Assessment (SOFA)-score, and 30-day mortality. Results Cytokines and complement activation were higher in the high IFABP group. In mediation analysis, patients on the 75th percentile of IFABP, compared to the 25th percentile, had 53% (95% CI, 33-74; p < 0.001) higher risk of dying, where 13 (95% CI, 3-23; p = 0.01) percentage points were mediated through an indirect effect of IL-6. Similarly, the indirect effect of IFABP through IL-6 on SOFA-score was significant, but smaller than potential other effects. Effects through IL-6 on circulatory variables, and all effects through TCC, were not statistically significant and/or small. Conclusion Effects of intestinal injury mediated through inflammation on organ dysfunction and mortality were limited. Small, but significant, effects through IL-6 were noted.Trial registration: ClinicalTrials.gov: NCT02648061.
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Affiliation(s)
- Bjørn Hoftun Farbu
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway
| | - Stian Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Randi Marie Mohus
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Thor Ueland
- Thrombosis Research Center (TREC), Division of Internal Medicine, University hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Institute of Internal Medicine, Oslo University Hospital (Rikshospitalet), Oslo, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital, Bodø, Norway
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Halvor Langeland
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital Trondheim, Norway
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Yao Y, Ba T, Bao B, Zhang S, Kong L. Sepsis as a Potential Risk Factor for Upper Gastrointestinal Bleeding in Critically Ill Patients: A Systematic Review and Meta-analysis. J Intensive Care Med 2024:8850666241252048. [PMID: 38813775 DOI: 10.1177/08850666241252048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Purpose: Sepsis is a common and critical condition in intensive care units (ICUs) known to complicate patient outcomes. Previous studies have indicated an association between sepsis and various ICU morbidities, including upper gastrointestinal bleeding (UGIB). However, the extent of this relationship and its implications in ICU settings remain inadequately quantified. This study aims to elucidate the association between sepsis and the risk of UGIB in ICU patients. Methods: A comprehensive meta-analysis was conducted, encompassing nine studies with a total of nearly 9000 participants. These studies reported events for both sepsis and nonsepsis patients separately. Pooled odds ratios (ORs) were calculated to assess the risk of UGIB in septic versus nonseptic ICU patients. Subgroup analyses were conducted based on age and study design, and both unadjusted and adjusted ORs were examined. Results: The pooled OR indicated a significant association between sepsis and UGIB (OR = 3.276, 95% CI: 1.931 to 5.557). Moderate heterogeneity was observed (I² = 43.9%). The association was significant in adults (pooled OR = 4.083) but not in children. No difference in association was found based on the study design. Unadjusted and adjusted ORs differed slightly, indicating the influence of confounding factors. Conclusion: This meta-analysis reveals a significant association between sepsis and an increased risk of UGIB in ICU patients, particularly in adults. These findings highlight the need for vigilant monitoring and proactive management of septic ICU patients to mitigate the risk of UGIB. Future research should focus on understanding the underlying mechanisms and developing tailored preventive strategies.
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Affiliation(s)
- Yanfen Yao
- Department of Intensive Care Medicine, Shandong Provincial Third Hospital, Shandong University, Jinan, China
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tejin Ba
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Bagenna Bao
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Shuanglin Zhang
- Department of Emergency, International Mongolian Hospital of Inner Mongolia, Hohhot, China
| | - Li Kong
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
- Department of Emergency Center, Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, China
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Ziaka M, Exadaktylos A. Exploring the lung-gut direction of the gut-lung axis in patients with ARDS. Crit Care 2024; 28:179. [PMID: 38802959 PMCID: PMC11131229 DOI: 10.1186/s13054-024-04966-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) represents a life-threatening inflammatory reaction marked by refractory hypoxaemia and pulmonary oedema. Despite advancements in treatment perspectives, ARDS still carries a high mortality rate, often due to systemic inflammatory responses leading to multiple organ dysfunction syndrome (MODS). Indeed, the deterioration and associated mortality in patients with acute lung injury (LI)/ARDS is believed to originate alongside respiratory failure mainly from the involvement of extrapulmonary organs, a consequence of the complex interaction between initial inflammatory cascades related to the primary event and ongoing mechanical ventilation-induced injury resulting in multiple organ failure (MOF) and potentially death. Even though recent research has increasingly highlighted the role of the gastrointestinal tract in this process, the pathophysiology of gut dysfunction in patients with ARDS remains mainly underexplored. This review aims to elucidate the complex interplay between lung and gut in patients with LI/ARDS. We will examine various factors, including systemic inflammation, epithelial barrier dysfunction, the effects of mechanical ventilation (MV), hypercapnia, and gut dysbiosis. Understanding these factors and their interaction may provide valuable insights into the pathophysiology of ARDS and potential therapeutic strategies to improve patient outcomes.
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Affiliation(s)
- Mairi Ziaka
- Clinic of Geriatric Medicine, Center of Geriatric Medicine and Rehabilitation, Kantonsspital Baselland, Bruderholz, Switzerland.
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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10
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Braun G. [Nutrition (therapy) in gastrointestinal failure]. Med Klin Intensivmed Notfmed 2024; 119:296-301. [PMID: 37985511 DOI: 10.1007/s00063-023-01082-z] [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: 04/02/2023] [Revised: 08/29/2023] [Accepted: 10/19/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The presence of gastrointestinal dysfunction is an outcome-relevant complication in critically ill ICU patients. AIMS, MATERIALS AND METHODS The following review aims to show the importance of gastrointestinal dysfunction. Multimodal therapy for gastroparesis and paralytic ileus is discussed. CONCLUSION Erythromycin and metoclopramide are options for gastroparesis, while neostigmine is commonly used for paralytic ileus.
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Affiliation(s)
- Georg Braun
- Internistisches Intensivzentrum, Medizinische Klinik 3 am Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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11
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Sun J, Li J, Deng Y, Yin X, Huangfu X, Ye Z, Zhou X, Chen Y, Yuan S, Wang X. The beneficial effects of neutrophil elastase inhibitor on gastrointestinal dysfunction in sepsis. Clin Transl Sci 2024; 17:e13829. [PMID: 38769746 PMCID: PMC11106555 DOI: 10.1111/cts.13829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 04/09/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
To investigate the effects of neutrophil elastase inhibitor (sivelestat sodium) on gastrointestinal function in sepsis. A reanalysis of the data from previous clinical trials conducted at our center was performed. Septic patients were divided into either the sivelestat group or the non-sivelestat group. The gastrointestinal dysfunction score (GIDS), feeding intolerance (FI) incidence, serum levels of intestinal barrier function and inflammatory biomarkers were recorded. The clinical severity and outcome variables were also documented. A total of 163 septic patients were included. The proportion of patients with GIDS ≥2 in the sivelestat group was reduced relative to that in the non-sivelestat group (9.6% vs. 22.5%, p = 0.047) on the 7th day of intensive care unit (ICU) admission. The FI incidence was also remarkably reduced in the sivelestat group in contrast to that in the non-sivelestat group (21.2% vs. 37.8%, p = 0.034). Furthermore, the sivelestat group had fewer days of FI [4 (3, 4) vs. 5 (4-6), p = 0.008]. The serum levels of d-lactate (p = 0.033), intestinal fatty acid-binding protein (p = 0.005), interleukin-6 (p = 0.001), white blood cells (p = 0.007), C-reactive protein (p = 0.001), and procalcitonin (p < 0.001) of the sivelestat group were lower than those of the non-sivelestat group. The sivelestat group also demonstrated longer ICU-free days [18 (0-22) vs. 13 (0-17), p = 0.004] and ventilator-free days [22 (1-24) vs. 16 (1-19), p = 0.002] compared with the non-sivelestat group. In conclusion, sivelestat sodium administration appears to improve gastrointestinal dysfunction, mitigate dysregulated inflammation, and reduce disease severity in septic patients.
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Affiliation(s)
- Jia‐Kui Sun
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Jing‐Jing Li
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Yi‐Hang Deng
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Xiang Yin
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Xiao‐Tian Huangfu
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Zi‐Yu Ye
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Xue‐Hui Zhou
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Yong‐Ming Chen
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Shou‐Tao Yuan
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
| | - Xiang Wang
- Department of Critical Care Medicine, Nanjing First HospitalNanjing Medical UniversityNanjingJiangsuChina
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Yébenes JC, Bordeje-Laguna ML, Lopez-Delgado JC, Lorencio-Cardenas C, Martinez De Lagran Zurbano I, Navas-Moya E, Servia-Goixart L. Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC). Nutrients 2024; 16:1157. [PMID: 38674847 PMCID: PMC11054493 DOI: 10.3390/nu16081157] [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: 03/01/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.
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Affiliation(s)
- Juan Carlos Yébenes
- Institut d’Assistència Sanitària (IAS)—Hospital Santa Caterina, 17007 Girona, Spain
| | | | - Juan Carlos Lopez-Delgado
- Hospital Clinic, Medical ICU, Clinical Institute of Internal Medicine & Dermatology (ICMiD), 08036 Barcelona, Spain;
| | | | | | | | - Lluis Servia-Goixart
- Intensive Care Department, Hospital Universitari Arnau de Vilanova, LLeida, 25198 Lleida, Spain;
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Cui X, Shi Y, He X, Zhang M, Zhang H, Yang J, Leng Y. Abdominal physical examinations in early stages benefit critically ill patients without primary gastrointestinal diseases: a retrospective cohort study. Front Med (Lausanne) 2024; 11:1338061. [PMID: 38654840 PMCID: PMC11037245 DOI: 10.3389/fmed.2024.1338061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/28/2024] [Indexed: 04/26/2024] Open
Abstract
Background Gastrointestinal (GI) function is critical for patients in intensive care units (ICUs). Whether and how much critically ill patients without GI primary diseases benefit from abdominal physical examinations remains unknown. No evidence from big data supports its possible additive value in outcome prediction. Methods We performed a big data analysis to confirm the value of abdominal physical examinations in ICU patients without GI primary diseases. Patients were selected from the Medical Information Mart for Intensive Care (MIMIC)-IV database and classified into two groups depending on whether they received abdominal palpation and auscultation. The primary outcome was the 28-day mortality. Statistical approaches included Cox regression, propensity score matching, and inverse probability of treatment weighting. Then, the abdominal physical examination group was randomly divided into the training and testing cohorts in an 8:2 ratio. And patients with GI primary diseases were selected as the validation group. Several machine learning algorithms, including Random Forest, Gradient Boosting Decision Tree, Adaboost, Extra Trees, Bagging, and Multi-Layer Perceptron, were used to develop in-hospital mortality predictive models. Results Abdominal physical examinations were performed in 868 (2.63%) of 33,007 patients without primary GI diseases. A significant benefit in terms of 28-day mortality was observed among the abdominal physical examination group (HR 0.75, 95% CI 0.56-0.99; p = 0.043), and a higher examination frequency was associated with improved outcomes (HR 0.62, 95%CI 0.40-0.98; p = 0.042). Machine learning studies further revealed that abdominal physical examinations were valuable in predicting in-hospital mortality. Considering both model performance and storage space, the Multi-Layer Perceptron model performed the best in predicting mortality (AUC = 0.9548 in the testing set and AUC = 0.9833 in the validation set). Conclusion Conducting abdominal physical examinations improves outcomes in critically ill patients without GI primary diseases. The results can be used to predict in-hospital mortality using machine learning algorithms.
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Affiliation(s)
- Xiao Cui
- Department of Intensive Care Units, Peking University Third Hospital, Beijing, China
| | - Yu Shi
- School of Mechanical Engineering, University of Science and Technology Beijing, Beijing, China
| | - Xinlei He
- Department of Intensive Care Units, Peking University Third Hospital, Beijing, China
| | - Mingyuan Zhang
- School of Mechanical Engineering, University of Science and Technology Beijing, Beijing, China
| | - Hua Zhang
- Department of Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Jianhong Yang
- School of Mechanical Engineering, University of Science and Technology Beijing, Beijing, China
| | - Yuxin Leng
- Department of Intensive Care Units, Peking University Third Hospital, Beijing, China
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Viner Smith E, Kouw IWK, Summers MJ, Louis R, Trahair L, O'Connor SN, Jones KL, Horowitz M, Chapman MJ, Chapple LAS. Comparison of energy intake in critical illness survivors, general medical patients, and healthy volunteers: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:275-283. [PMID: 38424664 DOI: 10.1002/jpen.2612] [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: 04/20/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group. OBJECTIVE To quantify energy intake and potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers. DESIGN A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test-meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition-impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range [IQR]) or number [percentage]). RESULTS Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS-CoV-2. Energy intake was lower in both patient groups than in health (ICU: 289 [288, 809], GM: 426 [336, 592], health: 815 [654, 1165] kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 [7.0, 11.0], 8.5 [7.0, 9.5], and 8.0 [6.0, 11.0]; and QoL; 60 [40-65], 50 [31-55], and 90 [81-95] out of 100. CONCLUSIONS Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.
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Affiliation(s)
- Elizabeth Viner Smith
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Imre W K Kouw
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Matthew J Summers
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Rhea Louis
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | - Stephanie N O'Connor
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Horowitz
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
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15
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Guan X, Chen D, Xu Y. Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China. JOURNAL OF INTENSIVE MEDICINE 2024; 4:137-159. [PMID: 38681796 PMCID: PMC11043647 DOI: 10.1016/j.jointm.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 05/01/2024]
Abstract
The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.
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Affiliation(s)
- Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, Beijing, China
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16
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De Rosa S, Battaglini D, Llompart-Pou JA, Godoy DA. Ten good reasons to consider gastrointestinal function after acute brain injury. J Clin Monit Comput 2024; 38:355-362. [PMID: 37418061 DOI: 10.1007/s10877-023-01050-0] [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: 04/21/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023]
Abstract
The brain-gut axis represents a bidirectional communication linking brain function with the gastrointestinal (GI) system. This interaction comprises a top-down communication from the brain to the gut, and a bottom-up communication from the gut to the brain, including neural, endocrine, immune, and humoral signaling. Acute brain injury (ABI) can lead to systemic complications including GI dysfunction. Techniques for monitoring GI function are currently few, neglected, and many under investigation. The use of ultrasound could provide a measure of gastric emptying, bowel peristalsis, bowel diameter, bowel wall thickness and tissue perfusion. Despite novel biomarkers represent a limitation in clinical practice, intra-abdominal pressure (IAP) is easy-to-use and measurable at bedside. Increased IAP can be both cause and consequence of GI dysfunction, and it can influence cerebral perfusion pressure and intracranial pressure via physiological mechanisms. Here, we address ten good reasons to consider GI function in patients with ABI, highlighting the importance of its assessment in neurocritical care.
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Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Denise Battaglini
- UO Clinica Anestesiologica e Terapia Intensiva, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Morreau M, Cheah E, Thakur S, Hong J, Hickey A, Phillips A, Windsor J. Luminal Delivery of Pectin-Modified Oxygen Microbubbles Mitigates Rodent Experimental Intestinal Ischemia. J Surg Res 2024; 296:603-611. [PMID: 38350299 DOI: 10.1016/j.jss.2024.01.035] [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: 09/06/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION Ischemic gut injury is common in the intensive care unit, impairs gut barrier function, and contributes to multiorgan dysfunction. One novel intervention to mitigate ischemic gut injury is the direct luminal delivery of oxygen microbubbles (OMB). Formulations of OMB can be modified to control the rate of oxygen delivery. This project examined whether luminal delivery of pectin-modified OMB (OMBp5) can reduce ischemic gut injury in a rodent model. METHODS The OMBp5 formulation was adapted to improve delivery of oxygen along the length of small intestine. Adult Sprague-Dawley rats (n = 24) were randomly allocated to three groups: sham-surgery (SS), intestinal ischemia (II), and intestinal ischemia plus luminal delivery of OMBp5 (II + O). Ischemia-reperfusion injury was induced by superior mesenteric artery occlusion for 45 min followed by reperfusion for 30 min. Outcome data included macroscopic score of mucosal injury, the histological score of gut injury, and plasma biomarkers of intestinal injury. RESULTS Macroscopic, microscopic data, and intestinal injury biomarker results demonstrated minimal intestinal damage in the SS group and constant damage in the II group. II + O group had a significantly improved macroscopic score throughout the gut mucosa (P = 0.04) than the II. The mean histological score of gut injury for the II + O group was significantly improved on the II group (P ≤ 0.01) in the proximal intestine only, within 30 cm of delivery. No differences were observed in plasma biomarkers of intestinal injury following OMBp5 treatment. CONCLUSIONS This proof-of-concept study has demonstrated that luminal OMBp5 decreases ischemic injury to the proximal small intestine. There is a need to improve oxygen delivery over the full length of the intestine. These findings support further studies with clinically relevant end points, such as systemic inflammation and vital organ dysfunction.
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Affiliation(s)
- Mathew Morreau
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Ernest Cheah
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sachin Thakur
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jiwon Hong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony Hickey
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Applied Surgery and Metabolism Laboratory, School of Biological Science, Faculty of Sciences, University of Auckland, Auckland, New Zealand
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
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Patel JJ, Lopez-Delgado JC, Stoppe C, McClave SA. Enteral nutrition in septic shock: a call for a paradigm shift. Curr Opin Crit Care 2024; 30:165-171. [PMID: 38441124 DOI: 10.1097/mcc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy. RECENT FINDINGS The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes. SUMMARY The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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Lohela TJ, Poikola S, Backmansson D, Lapatto-Reiniluoto O, Backman JT, Olkkola KT, Lilius TO. Influence of Intravenous S-Ketamine on the Pharmacokinetics of Oral Morphine in Healthy Volunteers. Anesth Analg 2024; 138:598-606. [PMID: 37733945 PMCID: PMC10852043 DOI: 10.1213/ane.0000000000006640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Subanesthetic ketamine may reduce perioperative consumption of opioids. We studied whether intravenous S-ketamine alters the pharmacokinetics of oral morphine in healthy volunteers. METHODS In this paired, randomized, double-blind, crossover trial, 12 participants under a 2-hour intravenous S-ketamine (0.57 mg/kg/h) or placebo infusion received oral morphine (0.2 mg/kg) at 30 minutes. Plasma concentrations of ketamine, morphine, and their major metabolites were quantified for 24 hours. The primary end point was area under the curve (AUC) 0-24 of morphine. Other pharmacokinetic variables for morphine and its metabolites were studied as secondary end points. The data were analyzed as between-phase comparisons for each participant using Wilcoxon matched-pairs signed-rank tests ( tmax ) or paired t -tests on log-transformed variables (other variables). RESULTS While the AUC 0-24 was similar between the 2 phases, S-ketamine reduced the AUC 0-1.5 of oral morphine by 69% (ratio to control, 0.31; 90% confidence interval [CI], 0.15-0.65; P = .0171) and increased its tmax from 0.5 (range, 0.50-1.5) to 1.0 hour (range, 0.50-4.0; P = .010). The AUC 0-1.5 of morphine-6-glucuronide (M6G) was reduced by 84% (0.16; 90% CI, 0.07-0.37; P = .0025) and maximum plasma concentration ( Cmax ) by 43% (0.57; 90% CI, 0.40-0.81; P = .0155), while its tmax was increased from 1.5 (range, 1.0-2.0) to 4.0 (range, 1.0-8.0; P = .0094) hours by S-ketamine. Similarly, the AUC 0-1.5 of morphine-3-glucuronide (M3G) was reduced by 85% (0.15; 90% CI, 0.05-0.43; P = .0083), and tmax increased from 1.0 (range, 0.5-1.5) to 4.0 hours (range, 1.0-8.0; P = .0063). In addition, the M6G-to-morphine and M3G-to-morphine metabolic AUC ratios were decreased by 47% (0.53; 90% CI, 0.39-0.71; P = .0033) and 52% (0.48; 90% CI, 0.27-0.85; P = .0043) during 0 to 1.5 hours and by 15% (0.85; 90% CI, 0.78-0.92; P = .0057) and 10% (0.90; 90% CI, 0.83-0.98; P = .0468) during 0 to 24 hours, respectively. One participant was excluded from the analyses due to vomiting in the S-ketamine phase. CONCLUSIONS Intravenous S-ketamine inhibited the metabolism of oral morphine and delayed its absorption, resulting in a net reduction in the exposure to morphine during the first 1.5 hours. Intravenous S-ketamine may delay the absorption and impair the efficacy of orally administered analgesics and other drugs.
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Affiliation(s)
- Terhi J. Lohela
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Satu Poikola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Daniel Backmansson
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Lapatto-Reiniluoto
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland
| | - Janne T. Backman
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Klaus T. Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tuomas O. Lilius
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Finnish Poison Information Center, Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Yang H, Lan W, Luo C, Huang Q, Zhong Z, Yang J, Xiang H, Chen T, Tang Y. Lactobacillus plantarum 24-7 improves postoperative bloating and hard stools by modulating intestinal microbiota in patients with congenital heart disease: a randomized controlled trial. Food Funct 2024; 15:2090-2102. [PMID: 38304947 DOI: 10.1039/d3fo05452g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Gastrointestinal symptoms are a common postoperative complication in patients with congenital heart disease (CHD), affecting their postoperative recovery. Probiotic intervention may be a promising therapeutic approach to alleviate postoperative gastrointestinal symptoms. This study aimed to evaluate the potential of Lactobacillus plantarum 24-7 (L. plantarum 24-7) in mitigating postoperative gastrointestinal symptoms and promoting patient recovery. Adult CHD patients scheduled for surgical intervention were recruited. One hundred and twenty patients were randomized and received L. plantarum or placebo intervention twice daily for ten days. Gastrointestinal symptoms were assessed utilizing the Gastrointestinal Symptom Rating Scale (GSRS). Various postoperative variables were analyzed across both groups. Alterations in gut microbiota were evaluated through 16S rRNA sequencing. 112 patients completed the study, with 55 in the probiotic group and 57 in the placebo group. While the disparity in overall postoperative GSRS scores between the two groups did not reach statistical significance (P = 0.067), marked differences were observed in bloating (P = 0.004) and hard stool (P = 0.030) scores. Furthermore, individuals within the probiotic group exhibited lower postoperative neutrophil counts (P = 0.007) and concurrently higher lymphocyte counts (P = 0.001). Variations in the diversity and composition of postoperative gut microbiota were discerned between the probiotic and placebo groups. Remarkably, no probiotic-related adverse events were documented. Supplementation with L. plantarum was well-tolerated and demonstrated partial efficacy in ameliorating gastrointestinal symptoms in postoperative CHD patients. Modulating the gut microbiota may be a potential mechanism by which L. plantarum exerts clinical benefits.
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Affiliation(s)
- Heng Yang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Wanqi Lan
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Chao Luo
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Qin Huang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Zhiwang Zhong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Juesheng Yang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
| | - Haiyan Xiang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
| | - Tingtao Chen
- The Institute of Translational Medicine, Jiangxi Medical College, Nanchang University, Nanchang, China.
- School of Pharmacy, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yanhua Tang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
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Wang Y, Yi Y, Zhang F, Yao YY, Chen YX, Wu CM, Wang RY, Yan M. Lung Ultrasound Score as a Predictor of Failure to Wean COVID-19 Elderly Patients off Mechanical Ventilation: A Prospective Observational Study. Clin Interv Aging 2024; 19:313-322. [PMID: 38404479 PMCID: PMC10887876 DOI: 10.2147/cia.s438714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/06/2024] [Indexed: 02/27/2024] Open
Abstract
Background The lung ultrasound score was developed for rapidly assessing the extent of lung ventilation, and it can predict failure to wean various types of patients off mechanical ventilation. Whether it is also effective for COVID-19 patients is unclear. Methods This single-center, prospective, observational study was conducted to assess the ability of the 12-region lung ultrasound score to predict failure to wean COVID-19 patients off ventilation. In parallel, we assessed whether right hemidiaphragmatic excursion or previously published predictors of weaning failure can apply to these patients. Predictive ability was assessed in terms of the area under the receiver operating characteristic curve (AUC). Results The mean age of the 35 patients in the study was (75 ± 9) years and 12 patients (37%) could not be weaned off mechanical ventilation. The lung ultrasound score predicted these failures with an AUC of 0.885 (95% CI 0.770-0.999, p < 0.001), and a threshold score of 10 provided specificity of 72.7% and sensitivity of 92.3%. AUCs were lower for previously published predictors of weaning failure, and right hemidiaphragmatic excursion did not differ significantly between the two groups. Conclusion The lung ultrasound score can accurately predict failure to wean critically ill COVID-19 patients off mechanical ventilation, whereas assessment of right hemidiaphragmatic excursion does not appear helpful in this regard. Trial Registration https://clinicaltrials.gov/ct2/show/NCT05706441.
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Affiliation(s)
- Ying Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Yu Yi
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Fan Zhang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Yuan-Yuan Yao
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Yue-Xiu Chen
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Chao-Min Wu
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Rui-Yu Wang
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Min Yan
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
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22
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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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23
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Nguyen DL, Schott LL, Lowen CC, Desai AM, Baumer DL, Miranowski MK, Cao Z, Torres KA. Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study. Clin Nutr ESPEN 2024; 59:270-278. [PMID: 38220386 DOI: 10.1016/j.clnesp.2023.12.007] [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: 07/25/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND & AIMS Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization. METHODS A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions. RESULTS Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001). CONCLUSIONS Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.
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Affiliation(s)
- Douglas L Nguyen
- Loma Linda University Medical Center, 11234 Anderson St., Loma Linda, CA, 92354, USA.
| | - Laura L Schott
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Cynthia C Lowen
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Amarsinh M Desai
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Dorothy L Baumer
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Mary K Miranowski
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Zhun Cao
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
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Yang J, Zou X, Wang R, Kang Y, Ou X, Wang B. MEAN ARTERIAL PRESSURE/NOREPINEPHRINE EQUIVALENT DOSE INDEX AS AN EARLY MEASURE FOR MORTALITY RISK IN PATIENTS WITH SHOCK ON VASOPRESSORS. Shock 2024; 61:253-259. [PMID: 38157472 DOI: 10.1097/shk.0000000000002298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
ABSTRACT Purpose: We aimed to investigate the association between the early mean arterial pressure (MAP)/norepinephrine equivalent dose (NEQ) index and mortality risk in patients with shock on vasopressors and further identify the breakpoint value of the MAP/NEQ index for high mortality risk. Methods: Based on the Medical Information Mart for Intensive Care IV database, we conducted a retrospective cohort study involving 19,539 eligible intensive care unit records assigned to three groups (first tertile, second tertile, and third tertile) by different MAP/NEQ indexes within 24 h of intensive care unit admission. The study outcomes were 7-, 14-, 21-, and 28-day mortality. A Cox model was used to examine the risk of mortality following different MAP/NEQ indexes. The receiving operating characteristic curve was used to evaluate the predictive ability of the MAP/NEQ index. The restricted cubic spline was applied to fit the flexible correlation between the MAP/NEQ index and risk of mortality, and segmented regression was further used to identify the breakpoint value of the MAP/NEQ index for high mortality risk. Results: Multivariate Cox analysis showed that a high MAP/NEQ index was independently associated with decreased mortality risks. The areas under the receiving operating characteristic curve of the MAP/NEQ index for different mortality outcomes were nearly 0.7. The MAP/NEQ index showed an L-shaped association with mortality outcomes or mortality risks. Exploration of the breakpoint value of the MAP/NEQ index suggested that a MAP/NEQ index less than 183 might be associated with a significantly increased mortality risk. Conclusions: An early low MAP/NEQ index was indicative of poor prognosis in patients with shock on vasopressors.
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Affiliation(s)
- Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xia Zou
- Clinical Research Management Department, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaofeng Ou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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25
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Wang Y, Li Y, Li Y, Li H, Zhang D. Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding. Nutrition 2024; 117:112255. [PMID: 37897987 DOI: 10.1016/j.nut.2023.112255] [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: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023]
Abstract
Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.
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Affiliation(s)
- Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yanhua Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Hongxiang Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
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26
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Zuo Z, Pei L, Liu T, Liu X, Chen Y, Hu Z. Investigation of Gut Microbiota Disorders in Sepsis and Sepsis Complicated with Acute Gastrointestinal Injury Based on 16S rRNA Genes Illumina Sequencing. Infect Drug Resist 2023; 16:7389-7403. [PMID: 38053580 PMCID: PMC10695144 DOI: 10.2147/idr.s440335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
Background Sepsis is a life-threatening organ dysfunction caused by the host's dysfunctional response to infection, which can cause acute gastrointestinal injury (AGI). The gut microbiota is dynamic and plays a role in the immune and metabolic. The aim of this study was to investigate the composition and function of gut microbiota in patients with sepsis, as well as the gut microbiome that may be involved in the occurrence of AGI. Methods A total of 23 stool samples from healthy control individuals and 41 stool samples from sepsis patients were collected. Patients with sepsis were followed up for one week to observe whether AGI has occurred. Finally, 41 patients included 21 sepsis complicated with AGI (referred to as Com-AGI) and 20 sepsis without complicated with AGI (referred to as No-AGI). The gut microbiota was analyzed by 16S rRNA gene sequencing, followed by composition analysis, difference analysis, correlation analysis, functional prediction analysis. Results The diversity and evenness of gut microbiota were decreased in patients with sepsis. Compared with No-AGI, the gut microbiota of Com-AGI has higher community diversity, richness, and phylogenetic diversity. Escherichia-Shigella, Blautia and Enterococcus may be important indicators of sepsis. The correlation analysis showed that aspartate aminotransferase (AST) and Barnesiella have the most significant positive correlation. Moreover, Clostridium_innocuum_group, Christensenellaceae_R-7_group and Eubacterium were all significantly correlated with LAC and DAO. Clostridium_innocuum_group, Barnesiella, Christensenellaceae_R-7_group and Eubacterium may play important roles in the occurrence of AGI in sepsis. PICRUSt analysis revealed multiple functional pathways involved in the relationship between gut microbiota and sepsis, including starch degradation V, glycogen degradation I (bacterial), Lipoic acid metabolism and Valine, leucine and isoleucine biosynthesis. BugBase analysis showed that the gut microbiota with Aerobic phenotype may play an important role in sepsis. Conclusion Dysfunction of gut microbiota was associated with sepsis and AGI in patients with sepsis.
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Affiliation(s)
- Zhigang Zuo
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
- Department of Critical Care Medicine, the First Hospital of Qinhuangdao, Qinhuangdao, Hebei, 066000, People’s Republic of China
- Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Liu Pei
- Department of Laboratory, the First Hospital of Qinhuangdao, Qinhuangdao, Hebei, 066000, People’s Republic of China
| | - Tianzhi Liu
- Department of Critical Care Medicine, the First Hospital of Qinhuangdao, Qinhuangdao, Hebei, 066000, People’s Republic of China
| | - Xiujuan Liu
- Department of Critical Care Medicine, the First Hospital of Qinhuangdao, Qinhuangdao, Hebei, 066000, People’s Republic of China
| | - Yuhong Chen
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
- Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, Hebei, 050011, People’s Republic of China
| | - Zhenjie Hu
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050011, People’s Republic of China
- Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, Hebei, 050011, People’s Republic of China
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Lv G, Zhang T, Wang L, Fu X, Wang Y, Yao H, Fang H, Xia X, Yang J, Wang B, Zhang Z, Jin X, Kang Y, Cheng Y, Wu Q. Prediction of prokinetic agents in critically ill patients with feeding intolerance: a prospective observational clinical study. Front Nutr 2023; 10:1244517. [PMID: 37964927 PMCID: PMC10641452 DOI: 10.3389/fnut.2023.1244517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/16/2023] [Indexed: 11/16/2023] Open
Abstract
Background Prokinetic agents are currently considered the first-line therapy to improve gastric emptying when feeding intolerance occurred in critically ill adults. In this study, we developed a technique to assess the feasibility of predicting prokinetic agent efficacy in critically ill patients. Methods The first images of each patient were obtained after EFI had occurred but before the first dose of prokinetic agents was administered and additional images were obtained every morning until the seventh day. The gastric antrum echodensity was recorded based on grayscale values (50th percentile, ED50; 85th percentile, ED85; mean, EDmean) and daily energy and protein intake was collected as the judgment for effective and ineffective group. A receiver operating characteristic curve was analyzed to distinguish the thresholds between the two groups and thus determine the ability of the gastric antrum echodensity to predict the efficacy of prokinetic agents. Results In total, 83 patients were analyzed. Patients in the ineffective group had a higher ED50 (58.13 ± 14.48 vs. 49.88 ± 13.78, p < 0.001, difference 95% CI: 5.68, 10.82), ED85 (74.81 ± 16.41 vs. 65.70 ± 16.05, p < 0.001, difference 95% CI:6.16, 12.05), and EDmean (60.18 ± 14.31 vs. 51.76 ± 14.08, p < 0.001, difference 95% CI: 5.85, 11.00) than those in the effective group. Patients in the effective group more easily reached the target energy 16.21 ± 7.98 kcal/kg vs. 9.17 ± 6.43 kcal/kg (p < 0.001), 0.72 ± 0.38 g/kg vs. 0.42 ± 0.31 g/kg (p < 0.001) than in the ineffective group intake by day. Conclusion The gastric antrum echodensity might serve as a tool for judging the efficacy of prokinetic agents, helping clinicians to decide whether to use prokinetic agents or place a post-pyloric tube when feeding intolerance occurs in critically ill patients.Clinical trial registration:http://www.chictr.org.cn/addproject2.aspx, ChiCTR2200058373. Registered 7 April 2022.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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Donmez-Altuntas H, Sahin Ergul S, Altin-Celik P, Bulut K, Eci Roglu H, Uzen R, Sahin GG, Ozer NT, Temel S, Arikan TB, Esmaoglu A, Yuksel RC, Sungur M, Gundogan K. Gut barrier protein levels in serial blood samples from critically ill trauma patients during and after intensive care unit stay. Eur J Trauma Emerg Surg 2023; 49:2203-2213. [PMID: 37296330 DOI: 10.1007/s00068-023-02298-6] [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: 02/09/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE In an effort to better manage critically ill patients hospitalised in the intensive care unit (ICU) after experiencing multiple traumas, the present study aimed to assess whether plasma levels of intestinal epithelial cell barrier proteins, including occludin, claudin-1, junctional adhesion molecule (JAM-1), tricellulin and zonulin, could be used as novel biomarkers. Additional potential markers such as intestinal fatty acid-binding protein (I-FABP), D-lactate, lipopolysaccharide (LPS) and citrulline were also evaluated. We also aimed to determine the possible relationships between the clinical, laboratory, and nutritional status of patients and the measured marker levels. METHODS Plasma samples from 29 patients (first, second, fifth and tenth days in the ICU and on days 7, 30 and 60 after hospital discharge) and 23 controls were subjected to commercial enzyme-linked immunosorbent assay (ELISA) testing. RESULTS On first day (admission) and on the second day, plasma I-FABP, D-lactate, citrulline, occludin, claudin-1, tricellulin and zonulin levels were high in trauma patients and positively correlated with lactate, C-reactive protein (CRP), number of days of ICU hospitalisation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and daily Sequential Organ Failure Assessment (SOFA) scores (P < 0.05-P < 0.01). CONCLUSION The results of the present study showed that occludin, claudin-1, tricellulin and zonulin proteins, as well as I-FABP, D-lactate and citrulline, may be used as promising biomarkers for the evaluation of disease severity in critically ill trauma patients, despite the complexity of the analysis of various barrier markers. However, our results should be supported by future studies.
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Affiliation(s)
| | - Serap Sahin Ergul
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- 100/2000 CoHE PhD Scholarship Program, Institute of Health Sciences, 38030, Kayseri, Turkey
| | - Pinar Altin-Celik
- Department of Medical Biology, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- 100/2000 CoHE PhD Scholarship Program, Institute of Health Sciences, 38030, Kayseri, Turkey
| | - Kadir Bulut
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Hamiyet Eci Roglu
- Department of Medical Biology, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- Health Services Vocational School, Alanya Alaaddin Keykubat University, 07425, Antalya, Turkey
| | - Ramazan Uzen
- Department of Medical Biology, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- 100/2000 CoHE PhD Scholarship Program, Institute of Health Sciences, 38030, Kayseri, Turkey
| | - Gulsah Gunes Sahin
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- 100/2000 CoHE PhD Scholarship Program, Institute of Health Sciences, 38030, Kayseri, Turkey
- Department of Nutrition and Dietetics, School of Health Sciences, Cappadocia University, 50000, Nevşehir, Turkey
| | - Nurhayat Tugra Ozer
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
- 100/2000 CoHE PhD Scholarship Program, Institute of Health Sciences, 38030, Kayseri, Turkey
| | - Sahin Temel
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Turkmen Bahadir Arikan
- Department of General Surgery, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Aliye Esmaoglu
- Department of Anaesthesiology and Reanimation, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Recep Civan Yuksel
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Murat Sungur
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
| | - Kursat Gundogan
- Division of Intensive Care Medicine, Department of Internal Medicine, Medical Faculty, Erciyes University, 38030, Kayseri, Turkey
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Kizilarslanoglu MC, Kollu K. Comment on: Association between gastrointestinal dysfunction score and disease severity and prognosis in critically ill patients. Clin Nutr 2023; 42:2081. [PMID: 37301686 DOI: 10.1016/j.clnu.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Muhammet Cemal Kizilarslanoglu
- University of Health Sciences Türkiye, Konya City Hospital, Department of Internal Medicine, Division of Geriatrics, Konya, Turkiye.
| | - Korhan Kollu
- University of Health Sciences Türkiye, Konya City Hospital, Department of Internal Medicine, Division of Intensive Care Medicine, Konya, Turkiye
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Aikawa G, Ouchi A, Sakuramoto H, Hoshino T, Enomoto Y, Shimojo N, Inoue Y. Association of early-onset constipation and diarrhoea with patient outcomes in critically ill ventilated patients: A retrospective observational cohort study. Aust Crit Care 2023; 36:737-742. [PMID: 36400625 DOI: 10.1016/j.aucc.2022.10.005] [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: 04/17/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Constipation and diarrhoea are closely related, but few studies have examined them simultaneously. OBJECTIVES The purpose of this study was to describe patient defecation status after intensive care unit (ICU) admission and determine the association between early-onset constipation and diarrhoea following ICU admission with outcomes for critically ill ventilated patients. METHODS Patients ventilated for ≥48 h in an ICU were retrospectively investigated, and their defecation status was assessed during the first week after admission. Early-onset constipation and diarrhoea were defined as onset during the first week of ICU admission. The patients were divided into three groups-normal defecation, constipation, and diarrhoea-and multiple comparisons were performed using the Kruskal-Wallis test and the Mann-Whitney U test with Bonferroni adjustment. Additionally, multivariable analysis was performed for mortality and length of stay using the linear and logistic regression models. RESULTS Of the 85 critically ill ventilated patients, 47 (55%) experienced early-onset constipation and 12 (14%) experienced early-onset diarrhoea. Patients with normal defecation and diarrhoea increased from the 4th and 5th day of ICU admission. Early-onset diarrhoea was significantly associated with the length of ICU stay (B = 7.534, 95% confidence interval: 0.116-14.951). CONCLUSIONS Early-onset constipation and diarrhoea were common in critically ill ventilated patients, and early-onset diarrhoea was associated with the length of ICU stay.
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Affiliation(s)
- Gen Aikawa
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan; Intensive Care Unit, University of Tsukuba Hospital, 2-1-1 Amakubo, Tsukuba, Ibaraki, Japan.
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, 6-11-1 Omika, Hitachi, Ibaraki, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, 1-1 Asty, Munakata, Fukuoka, Japan
| | - Tetsuya Hoshino
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
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Collie JTB, Jiang A, Abdelhamid YA, Ankravs M, Bellomo R, Byrne KM, Clancy A, Finnis ME, Greaves R, Tascone B, Deane AM. Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness. J Hum Nutr Diet 2023; 36:1214-1224. [PMID: 36919646 DOI: 10.1111/jhn.13162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients. METHODS Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group. RESULTS Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25). CONCLUSIONS Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.
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Affiliation(s)
- Jake T B Collie
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Agilent Technologies, Melbourne, Victoria, Australia
| | - Alice Jiang
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa Ankravs
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Kathleen M Byrne
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Annabelle Clancy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark E Finnis
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ronda Greaves
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Department of Biochemical Genetics, Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brianna Tascone
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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32
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Atmowihardjo LN, Schippers JR, Duijvelaar E, Bartelink IH, Bet PM, Swart NEL, van Rein N, Purdy K, Cavalla D, McElroy A, Fritchley S, Vonk Noordegraaf A, Endeman H, van Velzen P, Koopmans M, Bogaard HJ, Heunks L, Juffermans N, Schultz MJ, Tuinman PR, Bos LDJ, Aman J. Efficacy and safety of intravenous imatinib in COVID-19 ARDS: a randomized, double-blind, placebo-controlled clinical trial. Crit Care 2023; 27:226. [PMID: 37291677 DOI: 10.1186/s13054-023-04516-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
PURPOSE A hallmark of acute respiratory distress syndrome (ARDS) is hypoxaemic respiratory failure due to pulmonary vascular hyperpermeability. The tyrosine kinase inhibitor imatinib reversed pulmonary capillary leak in preclinical studies and improved clinical outcomes in hospitalized COVID-19 patients. We investigated the effect of intravenous (IV) imatinib on pulmonary edema in COVID-19 ARDS. METHODS This was a multicenter, randomized, double-blind, placebo-controlled trial. Invasively ventilated patients with moderate-to-severe COVID-19 ARDS were randomized to 200 mg IV imatinib or placebo twice daily for a maximum of seven days. The primary outcome was the change in extravascular lung water index (∆EVLWi) between days 1 and 4. Secondary outcomes included safety, duration of invasive ventilation, ventilator-free days (VFD) and 28-day mortality. Posthoc analyses were performed in previously identified biological subphenotypes. RESULTS 66 patients were randomized to imatinib (n = 33) or placebo (n = 33). There was no difference in ∆EVLWi between the groups (0.19 ml/kg, 95% CI - 3.16 to 2.77, p = 0.89). Imatinib treatment did not affect duration of invasive ventilation (p = 0.29), VFD (p = 0.29) or 28-day mortality (p = 0.79). IV imatinib was well-tolerated and appeared safe. In a subgroup of patients characterized by high IL-6, TNFR1 and SP-D levels (n = 20), imatinib significantly decreased EVLWi per treatment day (- 1.17 ml/kg, 95% CI - 1.87 to - 0.44). CONCLUSIONS IV imatinib did not reduce pulmonary edema or improve clinical outcomes in invasively ventilated COVID-19 patients. While this trial does not support the use of imatinib in the general COVID-19 ARDS population, imatinib reduced pulmonary edema in a subgroup of patients, underscoring the potential value of predictive enrichment in ARDS trials. Trial registration NCT04794088 , registered 11 March 2021. European Clinical Trials Database (EudraCT number: 2020-005447-23).
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Affiliation(s)
- Leila N Atmowihardjo
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Job R Schippers
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Erik Duijvelaar
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Imke H Bartelink
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Noortje E L Swart
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacology and Pharmacy, Leiden UMC, Albinusdreef 2, Leiden, The Netherlands
| | | | | | | | | | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Henrik Endeman
- Intensive Care, Erasmus University Medical Centre, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Patricia van Velzen
- Intensive Care, Dijklander Hospital, Location Purmerend, Waterlandlaan 250, Purmerend, The Netherlands
| | - Matty Koopmans
- Intensive Care, OLVG Hospital Location Oost, Oosterpark 9, Amsterdam, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Leo Heunks
- Intensive Care, Erasmus University Medical Centre, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Nicole Juffermans
- Intensive Care, OLVG Hospital Location Oost, Oosterpark 9, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus University, Rotterdam, The Netherlands
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Research and Development, Hamilton Medical AG, Chur, Switzerland
| | - Pieter R Tuinman
- Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Location VUmc, Room number 5A-074, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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Tyszko M, Lemańska-Perek A, Śmiechowicz J, Tomaszewska P, Biecek P, Gozdzik W, Adamik B. Citrulline, Intestinal Fatty Acid-Binding Protein and the Acute Gastrointestinal Injury Score as Predictors of Gastrointestinal Failure in Patients with Sepsis and Septic Shock. Nutrients 2023; 15:2100. [PMID: 37432225 DOI: 10.3390/nu15092100] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
Gastrointestinal (GI) failure can be both a cause of sepsis and a consequence of the systemic pro-inflammatory response in sepsis. Changes in biomarkers of enterocyte damage, citrulline and I-FABP (intestinal fatty acid binding protein), may indicate altered intestinal permeability and damage. The study group consisted of patients with sepsis (N = 28) and septic shock (N = 30); the control group included patients without infection (N = 10). Blood samples were collected for citrulline and I-FABP and a 4-point AGI score (acute GI injury score) was calculated to monitor GI function on days 1, 3, 5, 7, and 10. Citrulline concentrations in the study group were lower than in the control. Lower values were also noted in septic patients with shock when compared to the non-shock group throughout the study period. I-FABP was higher in the septic shock group than in the sepsis group only on days 1 and 3. Citrulline was lower in patients with GI failure (AGI III) when compared to AGI I/II, reaching significance on days 7 (p = 0.034) and 10 (p = 0.015); moreover, a higher AGI score was associated with an increased 28 day mortality (p = 0.038). The results indicate that citrulline measurements, along with the AGI assessment, have clinical potential in monitoring GI function and integrity in sepsis.
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Affiliation(s)
- Maciej Tyszko
- Clinical Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Anna Lemańska-Perek
- Department of Chemistry and Immunochemistry, Wroclaw Medical University, M. Sklodowskiej-Curie 48/50, 50-369 Wroclaw, Poland
| | - Jakub Śmiechowicz
- Clinical Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Paulina Tomaszewska
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Koszykowa 75, 00-662 Warsaw, Poland
| | - Przemyslaw Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Koszykowa 75, 00-662 Warsaw, Poland
- Faculty of Mathematics, Informatics and Mechanics, University of Warsaw, Banacha 2, 02-097 Warsaw, Poland
| | - Waldemar Gozdzik
- Clinical Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Barbara Adamik
- Clinical Department of Anesthesiology and Intensive Therapy, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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Joh D, Morreau M, Lee A, Pendharkar S, Stokes B, Warren R, Hickey A, Phillips AJ, Windsor JA. Intraluminal oxygen mitigates acute mesenteric ischaemia: a systematic review of methods and outcomes in animal studies. ANZ J Surg 2023; 93:859-868. [PMID: 36537566 DOI: 10.1111/ans.18211] [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: 11/01/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 04/14/2023]
Abstract
BACKGROUND Acute Mesenteric Ischaemic (AMI) is a rare condition with significant morbidity and mortality. Many causes of AMI exist, which usually begin with mucosal injury. Onset is insiduous and there is frequent diagnostic delay. Current treatments can only control established injury and prevent propagation, hence new interventions are needed. The prevention and treatment of AMI by intraluminal delivery of oxygen has yet to be investigated in the clinical setting. This article aims to systemically review experimental studies investigating this novel therapy. METHODS Following the PRISMA guidelines, searches of PubMed and Ovid MEDLINE databases were performed up to June 2022. Two independent investigators extracted the data. RESULTS There were 20 experimental studies, 16 of which used an occlusive ischaemia reperfusion model. Six different formulations were used to deliver intraluminal oxygen, with perflurocarbon being the most common. Studies consistently showed local and systemic benefits. Intraluminal oxygen therapy improved histological severity of mucosal injury in all studies when oxygen was delivered during the ischaemia phase, but could cause harm if given during the reperfusion phase. Improvement was also demonstrated in endpoints assessing intestinal function, biomarkers of intestinal damage, measures of systemic physiological derangement and mortality. CONCLUSION Intraluminal oxygenation appears to be an effective treatment for AMI. There remain significant questions regarding optimal timing and delivery formulation before clinical translation of this treatment strategy.
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Affiliation(s)
- Daniel Joh
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Mathew Morreau
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Applied Surgery and Metabolism Laboratory, School of Biological Science, University of Auckland, Auckland, New Zealand
| | - Angela Lee
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Sayali Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bruce Stokes
- Surgical Engineering Laboratory, Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Roger Warren
- Surgical Engineering Laboratory, Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Anthony Hickey
- Applied Surgery and Metabolism Laboratory, School of Biological Science, University of Auckland, Auckland, New Zealand
| | - Anthony J Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Applied Surgery and Metabolism Laboratory, School of Biological Science, University of Auckland, Auckland, New Zealand
- Surgical Engineering Laboratory, Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
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Abstract
PURPOSE OF REVIEW Study of organ crosstalk in critical illness has uncovered complex biological communication between different organ systems, but the role of microbiota in organ crosstalk has received limited attention. We highlight the emerging understanding of the gut-lung axis, and how the largest biomass of the human body in the gut may affect lung physiology in critical illness. RECENT FINDINGS Disruption of healthy gut microbial communities and replacement by disease-promoting pathogens (pathobiome) generates a maladaptive transmitter of messages from the gut to the lungs, connected via the portal venous and the mesenteric lymphatic systems. Gut barrier impairment allows for microbial translocation (living organisms or cellular fragments) to the lungs. Host-microbiota interactions in the gut mucosa can also impact lung physiology through microbial metabolite secretion or host-derived messengers (hormones, cytokines or immune cells). Clinical examples like the prevention of ventilator-associated pneumonia by selective decontamination of the digestive tract show that the gut-lung axis can be manipulated therapeutically. SUMMARY A growing body of evidence supports the pathophysiological relevance of the gut-lung axis, yet we are only at the brink of understanding the therapeutic and prognostic relevance of the gut microbiome, metabolites and host-microbe interactions in critical illness.
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Affiliation(s)
- Sridesh Nath
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine
| | - Georgios D Kitsios
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine
- Acute Lung Injury Center of Excellence
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lieuwe D J Bos
- Intensive Care
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Feeding intolerance during prolonged prone position in overweight and obese patients with severe COVID-19. NUTR HOSP 2023; 40:250-256. [PMID: 36880718 DOI: 10.20960/nh.04553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE the aim of this study was to compare the incidence rate of feeding intolerance (FI) during supine (SP) or prone positioning (PP) in critically ill COVID-19 patients. METHODS this was a retrospective cohort study of critically ill patients with overweight or obesity who received enteral nutrition (EN) in prone or supine positioning continuously during the first five days of mechanical ventilation. Nutritional risk, anthropometric measurements and body composition were assessed at the first 24 hours upon Intensive Care Unit (ICU) admission. Biochemical and clinical variables (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Kidney Injury [AKI] or comorbidities diagnosis) were collected. Pharmacotherapy (prokinetics, sedatives or neuromuscular blocking agents) and FI incidence (gastric residual volume [GRV] ≥ 200 ml or ≥ 500 ml, vomiting or diarrhea) were daily recorded. Constipation was defined as the absence of evacuation for five consecutive days. RESULTS eighty-two patients were included. Higher rate of prophylactic prokinetic prescription was observed in PP (42.8 vs 12.5 %, p = 0.002). GRV ≥ 200 in supine position was not different when compared to PP (p = 0.47). Vomiting episodes in supine compared to PP showed no difference between groups (15 % vs 24 %, p = 0.31). No differences in diarrhea events were detected (10 % vs 4.7 %, p = 0.36). Constipation was common in both groups (95 % vs 82 %, p = 0.06). CONCLUSION FI during prone position was not different in comparison to supine position. Routinely use of prokinetics in continuous prone position may help to prevent FI incidence. Algorithm development is necessary for FI prevention and treatment so to avoid EN interruptions and adverse clinical outcomes.
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Pérez-Calatayud ÁA, Carillo-Esper R. Role of gastric ultrasound to guide enteral nutrition in the critically ill. Curr Opin Clin Nutr Metab Care 2023; 26:114-119. [PMID: 36892960 DOI: 10.1097/mco.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Early initiation of enteral nutrition (EN) is often not feasible due to the high prevalence of gastrointestinal dysfunction that constitutes one of the leading nonavoidable causes for discontinuing or delaying enteral feeding in critically ill. This review summarizes current evidence on the role of gastric ultrasound as a management and monitoring tool for enteral nutrition in critically ill patients. RECENT FINDINGS The ultrasound meal accommodation test, the gastrointestinal and urinary track sonography (GUTS), and other gastric ultrasound protocols used to diagnose and treat gastrointestinal dysfunction in critically ill patients have not changed the outcome. However, this intervention could help clinicians with accurate daily clinical decisions. The dynamic changes in the cross-sectional area (CSA) diameter could help to access gastrointestinal dynamics results immediately, provide a valuable guide to initiate EN, predict feeding intolerance (FI), and aid in following treatment response. More studies are necessary to determine the complete scope and true added clinical value of these tests in critically ill patients. SUMMARY Using gastric point of care ultrasound (POCUS) is a noninvasive, radiation-free, and inexpensive method. Implementing the ultrasound meal accommodation test in ICU patients might become a step forward to ensure safe early enteral nutrition in critically ill patients.
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Reintam Blaser A, Preiser JC, Forbes A. The need for biomarkers to determine response to enteral nutrition during and after critical illness: an update. Curr Opin Clin Nutr Metab Care 2023; 26:120-128. [PMID: 36440798 DOI: 10.1097/mco.0000000000000893] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Biomarkers proposed to provide prognosis or to determine the response to enteral nutrition have been assessed in a number of experimental and clinical studies which are summarized in the current review. RECENT FINDINGS There are several pathophysiological mechanisms identified which could provide biomarkers to determine response to enteral nutrition. Several biomarkers have been studied, most of them insufficiently and none of them has made its way to clinical practice. Available studies have mainly assessed a simple association of a biomarker with outcomes, but are less focused on dynamic changes in the biomarker levels. Importantly, studies on pathophysiology and clinical features of gastrointestinal dysfunction, including enteral feeding intolerance, are also needed to explore the mechanisms potentially providing specific biomarkers. Not only an association of the biomarker with any adverse outcome, but also a rationale for repeated assessment to assist in treatment decisions during the course of illness is warranted. SUMMARY There is no biomarker currently available to reliably provide prognosis or determine the response to enteral nutrition in clinical practice, but identification of such a biomarker would be valuable to assist in clinical decision-making.
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Affiliation(s)
- Annika Reintam Blaser
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Jean-Charles Preiser
- Medical Direction, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Onuk S, Ozer NT, Ozel M, Sipahioglu H, Kahriman G, Baskol G, Temel S, Gundogan K, Akin A. Gastric ultrasound, citrulline, and intestinal fatty acid-binding protein as markers of gastrointestinal dysfunction in critically ill patients: A pilot prospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:429-436. [PMID: 36609803 DOI: 10.1002/jpen.2473] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/23/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Gastrointestinal (GI) dysfunction is common in the intensive care unit (ICU), although there is no consensus on biomarkers of GI dysfunction. We aimed to evaluate ultrasound-based gastric antrum measurements and serum intestinal fatty acid-binding protein (IFABP) and citrulline levels in relation to GI dysfunction in critically ill patients. METHODS Adult critically ill patients receiving enteral nutrition and stayed for in the ICU for ≥48 h was included. GI dysfunction was described using Gastrointestinal Dysfunction Score (GIDS). Gastric antrum measurements, including craniocaudal (CC) diameter, anteroposterior diameter, and antral-cross sectional area (CSA), as well as serum levels for IFABP and citrulline, were prospectively recorded at baseline and on day 3 and day 5 of enteral nutrition. The receiver operating characteristic (ROC) analysis was performed to evaluate gastric ultrasound parameters, serum IFABP, and citrulline concentrations in predicting GI dysfunction. RESULTS Thirty-nine participants with a median age of 60 years were recruited and 46.2% of participants had GI dysfunction. ROC analysis revealed that the cutoff value of CSA score to predict GI dysfunction was 4.48 cm2 , which provided 72.7% sensitivity and 77.2% specificity (area under the curve = 0.768, 95% CI: 0.555-0.980). At baseline, gastric residual volume was highly correlated with CC diameter and CSA (r = 0.764, P < 0.001 and r = 0.675, P < 0.001, respectively). Serum IFABP and citrulline levels had no correlation with GI dysfunction or gastric ultrasound parameters (P > 0.05). CONCLUSION CSA was associated with GI dysfunction in critically ill patients. Serum IFABP and citrulline concentrations were poor in predicting GI dysfunction.
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Affiliation(s)
- Sevda Onuk
- Division of Intensive Care Unit, Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Nurhayat Tugra Ozer
- Department of Clinical Nutrition, Health Science Institute, Erciyes University, Kayseri, Turkey
| | - Merve Ozel
- Department of Clinical Biochemistry, Erciyes University, Kayseri, Turkey
| | - Hilal Sipahioglu
- Division of Intensive Care Unit, Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Güven Kahriman
- Department of Radiology, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Gulden Baskol
- Department of Clinical Biochemistry, Erciyes University, Kayseri, Turkey
| | - Sahin Temel
- Division of Intensive Care, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Kursat Gundogan
- Division of Intensive Care, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Aynur Akin
- Division of Anestesiology and Reanimation Intensive Care, School of Medicine, Erciyes University, Kayseri, Turkey
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Hoftun Farbu B, Langeland H, Ueland T, Michelsen AE, Jørstad Krüger A, Klepstad P, Nordseth T. Intestinal injury in cardiac arrest is associated with multiple organ dysfunction: A prospective cohort study. Resuscitation 2023; 185:109748. [PMID: 36842675 DOI: 10.1016/j.resuscitation.2023.109748] [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: 01/12/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND The impact of intestinal injury in cardiac arrest is not established. The first aim of this study was to assess associations between clinical characteristics in out-of-hospital cardiac arrest (OHCA) and a biomarker for intestinal injury, Intestinal Fatty Acid Binding Protein (IFABP). The second aim was to assess associations between IFABP and multiple organ dysfunction and 30-day mortality. METHODS We measured plasma IFABP in 50 patients at admission to intensive care unit (ICU) after OHCA. Demographic and clinical variables were analysed by stratifying patients on median IFABP, and by linear regression. We compared Sequential Organ Failure Assessment (SOFA) score, haemodynamic variables, and clinical-chemistry tests at day two between the "high" and "low" IFABP groups. Logistic regression was applied to assess factors associated with 30-day mortality. RESULTS Several markers of whole body ischaemia correlated with intestinal injury. Duration of arrest and lactate serum concentrations contributed to elevated IFABP in a multivariable model (p < 0.01 and p = 0.04, respectively). At day two, all seven patients who had died were in the "high" IFABP group, and all six patients who had been transferred to ward were in the "low" group. Of patients still treated in the ICU, the "high" group had higher total, renal and respiratory SOFA score (p < 0.01) and included all patients receiving inotropic drugs. IFABP predicted mortality (OR 16.9 per standard deviation increase, p = 0.04). CONCLUSION Cardiac arrest duration and lactate serum concentrations were risk factors for intestinal injury. High levels of IFABP at admission were associated with multiple organ dysfunction and mortality. TRIAL REGISTRATION ClinicalTrials.gov: NCT02648061.
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Affiliation(s)
- Bjørn Hoftun Farbu
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway; Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway.
| | - Halvor Langeland
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway; Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Thor Ueland
- K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital (Rikshospitalet), Oslo, Norway
| | - Annika E Michelsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital (Rikshospitalet), Oslo, Norway
| | - Andreas Jørstad Krüger
- Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Norwegian Air Ambulance Foundation, Department of Research and Development, Oslo, Norway; Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway; Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Trond Nordseth
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway; Institute of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Jiang M, Zhang X, Zhang Y, Liu Y, Geng R, Liu H, Sun Y, Wang B. The Effects of Perioperative Probiotics on Postoperative Gastrointestinal Function in Patients with Brain Tumors: A Randomized, Placebo-Controlled Study. Nutr Cancer 2023; 75:1132-1142. [PMID: 37139872 DOI: 10.1080/01635581.2023.2178929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The incidence of postoperative gastrointestinal dysfunction among neurosurgical patients is as high as 80%. Probiotics help to maintain gastrointestinal barrier defense, provide competitive adherence to mucus and epithelial cells, and regulate gastrointestinal motility. Therefore, the purpose of this study was to investigate whether probiotics enhance gastrointestinal health after craniotomy in patients with brain tumors. This study was a 15-day, prospective, randomized, double-blind, placebo-controlled trial for patients being treated with elective craniotomy for brain tumors. Participants were randomly divided into the probiotics group (4 g probiotics, twice daily) and placebo group. The primary outcome was the time of first stool after surgery. The secondary outcomes included assessments of the gastrointestinal function, changes in gastrointestinal permeability and clinical outcomes. We enrolled a total of 200 participants (probiotics: 100; placebo: 100) and followed the principles of intention-to-treat analysis. The time of first stool and flatus were significantly shorter in the probiotics group compared to the placebo group (P < 0.001, respectively). No significant trends were observed for any other of the secondary outcome variables. Our findings suggest that probiotics can improve the gastrointestinal mobility of patients received craniotomy, and this improvement cannot be explained by changes in gastrointestinal permeability.
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Affiliation(s)
- Mengyang Jiang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Clinical Epidemiology, School of Public Health, Capital Medical University, Beijing, China
| | - Yiqiang Zhang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Ran Geng
- Zhongke Yikang Biological Technology Company, Beijing, China
| | - Haixia Liu
- Zhongke Yikang Biological Technology Company, Beijing, China
| | - Yongxing Sun
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Baoguo Wang
- Department of Anesthesiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
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Sun BF, Zhang F, Chen QP, Wei Q, Zhu WT, Ji HB, Zhang XY. Improvement of inflammatory response and gastrointestinal function in perioperative of cholelithiasis by Modified Xiao-Cheng-Qi decoction. World J Clin Cases 2023; 11:830-843. [PMID: 36818637 PMCID: PMC9928702 DOI: 10.12998/wjcc.v11.i4.830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND In the perioperative period of biliary surgery, various factors can induce the release of a large number of inflammatory factors, leading to an imbalance in pro-inflammatory and anti-inflammatory responses and resulting in gastrointestinal (GI) dysfunction. Enhanced Recovery After Surgery protocols in biliary surgery have been shown to reduce the stress response and accelerate postoperative recovery. It is crucial to reduce the inflammatory response and promote the recovery of GI function after biliary surgery, both of which are the basis and key for perioperative care and postoperative recovery.
AIM To better understand the effects of Modified Xiao-Cheng-Qi decoction (MXD) on inflammatory response and GI function in the perioperative management of cholelithiasis and their correlation.
METHODS This was a prospective randomized placebo-controlled trial, in which 162 patients who received biliary tract surgery were randomly assigned to three groups: MXD group, XD group, and placebo-control group. The observed parameters included frequency of bowel sounds, time of first flatus and defecation, time of diet, and amount of activity after surgery. The serum levels of C-reactive protein (CRP), interleukin (IL)-6, IL-10, serum amyloid A protein (SAA), and substance P were measured by the enzyme-linked immunosorbent assay. Then, the spearman correlation coefficient was used to analyze the relationship between the indicators of GI function and inflammation.
RESULTS Compared to the placebo-control, improvements in GI function were observed in the MXD groups including reduced incidence of nausea, vomiting, and bloating; and earlier first exhaust time, first defecation time, and feeding time after surgery (P < 0.05). On the 1st and 2nd d after surgery, IL-6, CRP and SAA levels in MXD group were lower than that in placebo control, but substance P level was higher, compared to the control (P < 0.05). Functional diarrhea occurred in both MXD and XD groups without any other adverse effects, toxic reactions, and allergic reactions. Diarrhea was relieved after the discontinuation of the investigational remedies. Bowel sounds at 12 h after surgery, the occurring time of the first flatus, first defecation, postoperative liquid diet and semi-liquid diet were significantly correlated with levels of IL-6, CRP, SAA and substance P on second day after surgery (P < 0.05).
CONCLUSION Treatment with MXD can relieve inflammatory response and improve GI function after surgery. Moreover, there are significant correlations between them. Furthermore, it does not cause serious adverse reactions.
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Affiliation(s)
- Bao-Fang Sun
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Fan Zhang
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Qiang-Pu Chen
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Qiang Wei
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Wen-Tao Zhu
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Hai-Bin Ji
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
| | - Xing-Yuan Zhang
- Department of Hepatobiliary Surgery, Binzhou Medical University Hospital, Binzhou 256603, Shandong Province, China
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Gunst J, Casaer MP, Preiser JC, Reignier J, Van den Berghe G. Toward nutrition improving outcome of critically ill patients: How to interpret recent feeding RCTs? Crit Care 2023; 27:43. [PMID: 36707883 PMCID: PMC9883882 DOI: 10.1186/s13054-023-04317-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/11/2023] [Indexed: 01/29/2023] Open
Abstract
Although numerous observational studies associated underfeeding with poor outcome, recent randomized controlled trials (RCTs) have shown that early full nutritional support does not benefit critically ill patients and may induce dose-dependent harm. Some researchers have suggested that the absence of benefit in RCTs may be attributed to overrepresentation of patients deemed at low nutritional risk, or to a too low amino acid versus non-protein energy dose in the nutritional formula. However, these hypotheses have not been confirmed by strong evidence. RCTs have not revealed any subgroup benefiting from early full nutritional support, nor benefit from increased amino acid doses or from indirect calorimetry-based energy dosing targeted at 100% of energy expenditure. Mechanistic studies attributed the absence of benefit of early feeding to anabolic resistance and futile catabolism of extra provided amino acids, and to feeding-induced suppression of recovery-enhancing pathways such as autophagy and ketogenesis, which opened perspectives for fasting-mimicking diets and ketone supplementation. Yet, the presence or absence of an anabolic response to feeding cannot be predicted or monitored and likely differs over time and among patients. In the absence of such monitor, the value of indirect calorimetry seems obscure, especially in the acute phase of illness. Until now, large feeding RCTs have focused on interventions that were initiated in the first week of critical illness. There are no large RCTs that investigated the impact of different feeding strategies initiated after the acute phase and continued after discharge from the intensive care unit in patients recovering from critical illness.
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Affiliation(s)
- Jan Gunst
- grid.5596.f0000 0001 0668 7884Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Michael P. Casaer
- grid.5596.f0000 0001 0668 7884Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jean-Charles Preiser
- grid.4989.c0000 0001 2348 0746Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Reignier
- grid.4817.a0000 0001 2189 0784Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Greet Van den Berghe
- grid.5596.f0000 0001 0668 7884Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Zhang H, Hu S, Xu D, Shen H, Jin H, Yang J, Zhang X. Risk Factors for Carbapenem Resistant Gram Negative Bacteria (CR-GNB) Carriage Upon Admission to the Gastroenterology Department in a Tertiary First Class Hospital of China: Development and Assessment of a New Predictive Nomogram. Infect Drug Resist 2022; 15:7761-7775. [PMID: 36597451 PMCID: PMC9805728 DOI: 10.2147/idr.s396596] [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: 11/11/2022] [Accepted: 12/14/2022] [Indexed: 12/29/2022] Open
Abstract
Background With the increasing number of critically ill patients in the gastroenterology department (GED), infections associated with Carbapenem resistant gram-negative bacteria (CR-GNB) are of great concern in GED. As the turn-around time (TAT) for a positive screening culture result is slow, contact precaution and pre-emptive isolation, cohorting methods should be undertaken immediately on admission for high-risk patients. Accurate prediction tools for CR-GNB colonization in GED can help determine target populations upon admission. And thus, clinicians and nurses can implement preventive measures more timely and effectively. Objective The purpose of the current study was to develop and internally validate a CR-GNB carrier risk predictive nomogram for a Chinese population in GED. Methods Based on a training dataset of 400 GED patients collected between January 2020 and December 2021, we developed a model to predict CR-GNB carrier risk. A rectal swab was used to evaluate the patients' CR-GNB colonization status microbiologically. We optimized features selection using the least absolute shrinkage and selection operator regression model (LASSO). In order to develop a predicting model, multivariable logistic regression analysis was then undertaken. Various aspects of the predicting model were evaluated, including discrimination, calibration, and clinical utility. We assessed internal validation using bootstrapping. Results The prediction nomogram includes the following predictors: Transfer from another hospital (Odds ratio [OR] 3.48), High Eastern Cooperative Oncology Group (ECOG) performance status (OR 2.61), Longterm in healthcare facility (OR 10.94), ICU admission history (OR 9.03), Blood stream infection history (OR 3.31), Liver cirrhosis (OR 4.05) and Carbapenem usage history within 3 month (OR 2.71). The model demonstrated good discrimination and good calibration. Conclusion With an estimate of individual risk using the nomogram developed in this study, clinicians and nurses can take more timely infection preventive measures on isolation, cohorting and medical interventions.
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Affiliation(s)
- Hongchen Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Shanshan Hu
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Dongchao Xu
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Hongzhang Shen
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Hangbin Jin
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Jianfeng Yang
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China
| | - Xiaofeng Zhang
- The Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Zhejiang, People’s Republic of China,Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Zhejiang, People’s Republic of China,Hangzhou Institute of Digestive Disease, Zhejiang, People’s Republic of China,Correspondence: Xiaofeng Zhang, Department of Gastroenterology, Hangzhou First People’s Hospital, NO. 261 HuanSha Road, Hangzhou, 310006, People’s Republic of China, Tel +86-13588296257, Fax +86-571-56005600, Email
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Bourcier S, Ulmann G, Jamme M, Savary G, Paul M, Benghanem S, Lavillegrand JR, Schmidt M, Luyt CE, Maury E, Combes A, Pène F, Neveux N, Cariou A. A multicentric prospective observational study of diagnosis and prognosis features in ICU mesenteric ischemia: the DIAGOMI study. Ann Intensive Care 2022; 12:113. [PMID: 36527517 PMCID: PMC9759607 DOI: 10.1186/s13613-022-01092-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Non-occlusive mesenteric ischemia (NOMI) is a challenging diagnosis and is associated with extremely high mortality in critically ill patients, particularly due to delayed diagnosis and when complicated by intestinal necrosis. Plasma citrulline and intestinal-fatty acid binding protein (I-FABP) have been proposed as potential biomarkers, but have never been studied prospectively in this setting. We aimed to investigate diagnostic features, the accuracy of plasma citrulline and I-FABP to diagnose NOMI and intestinal necrosis as well as prognosis. METHODS We conducted a prospective observational study in 3 tertiary ICU centers in consecutive patients with NOMI suspicion defined by at least two inclusion criteria among: new-onset or worsening circulatory failure, gastrointestinal dysfunction, biological signs and CT-scan signs of mesenteric ischemia. Diagnosis features and outcomes were compared according to NOMI, intestinal necrosis or ruled out diagnosis using stringent classification criteria. RESULTS Diagnosis of NOMI was suspected in 61 patients and confirmed for 33 patients, with intestinal necrosis occurring in 27 patients. Clinical digestive signs, routine laboratory results and CT signs of mesenteric ischemia did not discriminate intestinal necrosis from ischemia without necrosis. Plasma I-FABP was significantly increased in presence of intestinal necrosis (AUC 0.83 [0.70-0.96]). A threshold of 3114 pg/mL showed a sensitivity of 70% [50-86], specificity of 85% [55-98], a negative predictive value of 58% [36-93] and a positive predictive value 90% [67-96] for intestinal necrosis diagnosis. When intestinal necrosis was present, surgical resection was significantly associated with ICU survival (38.5%), whereas no patient survived without necrosis resection (HR = 0.31 [0.12-0.75], p = 0.01). CONCLUSION In critically ill patients with NOMI, intestinal necrosis was associated with extremely high mortality, and increased survival when necrosis resection was performed. Elevated plasma I-FABP was associated with the diagnosis of intestinal necrosis. Further studies are needed to investigate plasma I-FABP and citrulline performance in less severe forms of NOMI.
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Affiliation(s)
- Simon Bourcier
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.411439.a0000 0001 2150 9058Assistance Publique-Hôpitaux de Paris, AP-HP, Médecine Intensive Réanimation, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Ulmann
- grid.5842.b0000 0001 2171 2558Clinical Chemistry Department, AP-HP Centre, Hôpital Cochin, Université de Paris, Paris, France ,grid.5842.b0000 0001 2171 2558EA 4466 PRETRAM, Faculty of Pharmacy, Université de Paris, Paris, France
| | - Matthieu Jamme
- grid.418433.90000 0000 8804 2678Réanimation Polyvalente, Hôpital Privé de l’Ouest Parisien, Ramsay Générale de Santé, Trappes, France ,grid.12832.3a0000 0001 2323 0229INSERM U1018, Centre de Recherche en Epidémiologie et Santé des Populations, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), Université Versailles Saint-Quentin, Villejuif, France
| | - Guillaume Savary
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Marine Paul
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Sarah Benghanem
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Jean-Rémi Lavillegrand
- grid.50550.350000 0001 2175 4109AP-HP, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Médecine Intensive Réanimation, Paris, France
| | - Matthieu Schmidt
- grid.411439.a0000 0001 2150 9058Assistance Publique-Hôpitaux de Paris, AP-HP, Médecine Intensive Réanimation, Pitié-Salpêtrière Hospital, Paris, France ,grid.462844.80000 0001 2308 1657INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Charles-Edouard Luyt
- grid.411439.a0000 0001 2150 9058Assistance Publique-Hôpitaux de Paris, AP-HP, Médecine Intensive Réanimation, Pitié-Salpêtrière Hospital, Paris, France ,grid.462844.80000 0001 2308 1657INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Eric Maury
- grid.50550.350000 0001 2175 4109AP-HP, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Médecine Intensive Réanimation, Paris, France
| | - Alain Combes
- grid.411439.a0000 0001 2150 9058Assistance Publique-Hôpitaux de Paris, AP-HP, Médecine Intensive Réanimation, Pitié-Salpêtrière Hospital, Paris, France ,grid.462844.80000 0001 2308 1657INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Frédéric Pène
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Nathalie Neveux
- grid.5842.b0000 0001 2171 2558Clinical Chemistry Department, AP-HP Centre, Hôpital Cochin, Université de Paris, Paris, France ,grid.5842.b0000 0001 2171 2558EA 4466 PRETRAM, Faculty of Pharmacy, Université de Paris, Paris, France
| | - Alain Cariou
- grid.411784.f0000 0001 0274 3893Medical Intensive Care Unit, AP-HP, Institut Cochin, Cochin Hospital, Centre & Université de Paris, INSERM U1016, CNRS UMR8104, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
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Intestinal Fatty Acid Binding Protein (I-FABP) as a Prognostic Marker in Critically Ill COVID-19 Patients. Pathogens 2022; 11:pathogens11121526. [PMID: 36558860 PMCID: PMC9784725 DOI: 10.3390/pathogens11121526] [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: 10/25/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Gastrointestinal symptoms are common in critically ill COVID-19 patients. There is currently no generally recognized method of assessing gastrointestinal injury in unconscious or sedated intensive care unit (ICU) patients. I-FABP (intestinal fatty acid binding protein) and citrulline have previously been studied as potential biomarkers of enterocyte damage in various gastrointestinal tract diseases, and changes in the levels of these markers may reflect intestinal wall damage in COVID-19. Patients with critical COVID-19, with diagnosed sepsis, or septic shock requiring ICU treatment were included in the study. Blood samples for citrulline and I-FABP were taken daily from day 1 to 5. I-FABP levels were significantly higher in patients who eventually died from COVID-19 than in survivors, and the optimal I-FABP cut-off point for predicting 28-day mortality was 668.57 pg/mL (sensitivity 0.739, specificity 0.765). Plasma levels of I-FABP, but not citrulline, were associated with significantly higher mortality and appeared to be a predictor of poor outcome in multivariate logistic regression analysis. In conclusion, I-FABP seems to be an effective prognostic marker in critically ill COVID-19 patients. Assessing mortality risk based on intestinal markers may be helpful in making clinical decisions regarding the management of intestinal injury, imaging diagnostics, and potential surgical interventions.
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Liu R, Paz M, Siraj L, Boyd T, Salamone S, Lite TLV, Leung KM, Chirinos JD, Shang HH, Townsend MJ, Rho J, Ni P, Ranganath K, Violante AD, Zhao Z, Silvernale C, Ahmad I, Krasnow NA, Barnett ES, Harisinghani M, Kuo B, Black KE, Staller K. Feeding intolerance in critically ill patients with COVID-19. Clin Nutr 2022; 41:3069-3076. [PMID: 33934924 PMCID: PMC8007186 DOI: 10.1016/j.clnu.2021.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Early reports suggest significant difficulty with enteral feeding in critically ill COVID-19 patients. This study aimed to characterize the prevalence, clinical manifestations, and outcomes of feeding intolerance in critically ill patients with COVID-19. METHODS We examined 323 adult patients with COVID-19 admitted to the intensive care units (ICUs) of Massachusetts General Hospital between March 11 and June 28, 2020 who received enteral nutrition. Systematic chart review determined prevalence, clinical characteristics, and hospital outcomes (ICU complications, length of stay, and mortality) of feeding intolerance. RESULTS Feeding intolerance developed in 56% of the patients and most commonly manifested as large gastric residual volumes (83.9%), abdominal distension (67.2%), and vomiting (63.9%). Length of intubation (OR 1.05, 95% CI 1.03-1.08), ≥1 GI symptom on presentation (OR 0.76, 95% CI 0.59-0.97), and severe obesity (OR 0.29, 95% CI 0.13-0.66) were independently associated with development of feeding intolerance. Compared to feed-tolerant patients, patients with incident feeding intolerance were significantly more likely to suffer cardiac, renal, hepatic, and hematologic complications during their hospitalization. Feeding intolerance was similarly associated with poor outcomes including longer ICU stay (median [IQR] 21.5 [14-30] vs. 15 [9-22] days, P < 0.001), overall hospitalization time (median [IQR] 30.5 [19-42] vs. 24 [15-35], P < 0.001) and in-hospital mortality (33.9% vs. 16.1%, P < 0.001). Feeding intolerance was independently associated with an increased risk of death (HR 3.32; 95% CI 1.97-5.6). CONCLUSIONS Feeding intolerance is a frequently encountered complication in critically ill COVID-19 patients in a large tertiary care experience and is associated with poor outcomes.
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Affiliation(s)
- Rebecca Liu
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Mary Paz
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Layla Siraj
- Harvard Medical School, Boston, MA 02115, USA,Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, MA 02115, USA
| | - Taylor Boyd
- Harvard Medical School, Boston, MA 02115, USA
| | | | | | - Krystle M. Leung
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | | | | | | | - Junsung Rho
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Peiyun Ni
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | | | - April D. Violante
- Division of Clinical Nutrition, Department of Nutrition and Food Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Zezhou Zhao
- Harvard Medical School, Boston, MA 02115, USA,Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, MA 02115, USA
| | - Casey Silvernale
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Imama Ahmad
- Department of Medicine, North Shore Medical Center, Salem, MA 01970, USA
| | | | | | - Mukesh Harisinghani
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Braden Kuo
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Katharine E. Black
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Kyle Staller
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA,Corresponding author. Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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48
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Jenkins B, Calder PC, Marino LV. A scoping review considering potential biomarkers or functional measures of gastrointestinal dysfunction and enteral feeding intolerance in critically ill adults. Clin Nutr ESPEN 2022; 52:331-339. [PMID: 36513473 DOI: 10.1016/j.clnesp.2022.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND & AIM Enteral feeding intolerance (EFI) as a result of gastrointestinal (GI) dysfunction in critically ill adults can lead to suboptimal nutritional delivery, increasing the risk of hospital acquired malnutrition. There are no validated measures of EFI or consensus as to which measures could be used to define EFI. The aim of this scoping review is to explore the validity of biomarkers, physiological or functional measures of GI dysfunction and EFI in critically ill adults characterising their use in routine clinical practice to identify those with GI dysfunction to better guide nutritional support. METHODS Database searches were completed in Ovid MEDLINE, Embase, CINAHL and Web of Science using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The search was performed until June 2022. Articles were included if they reported original studies that identify potential biomarkers or functional measures of EFI in critically ill adults. A nine-stage process was completed to extract and complete data synthesis. RESULTS 139 unique articles were identified. Following review of titles and abstracts, 114 of these articles were excluded, three further articles were excluded after full text review and 22 articles met the inclusion criteria. A thematic analysis of the articles included identified three overarching themes of GI dysfunction: (1) Serum biomarkers, (2) Physiological markers, and (3) Functional markers. Within the category of serum biomarkers, a further three sub-categories were identified: (i) enterohormones, (ii) markers of enterocyte function, and iii) cytokines and neurotransmitters. Some associations were seen between EFI and heparin binding protein, intra-abdominal pressure, cholecystokinin and acetylcholine levels but no markers are currently suitable for daily clinical use. CONCLUSIONS Further larger studies are required to characterise the relationships between serum biomarkers, physiological and functional makers of GI dysfunction in critically ill adults. A robust definition of GI dysfunction should be included in any future research.
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Affiliation(s)
- Bethan Jenkins
- Department of Dietetics/SLT, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK.
| | - Philip C Calder
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Luise V Marino
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK; Paediatric Intensive Care Unit, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
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49
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Yang YJ, Su S, Zhang Y, Wu D, Wang C, Wei Y, Peng X. Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats. BURNS & TRAUMA 2022; 10:tkac042. [PMID: 36420355 PMCID: PMC9678637 DOI: 10.1093/burnst/tkac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats. METHODS Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups. RESULTS Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups. CONCLUSIONS Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.
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Affiliation(s)
| | | | | | - Dan Wu
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Chao Wang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, 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
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50
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Chapple LAS, Parry SM, Schaller SJ. Attenuating Muscle Mass Loss in Critical Illness: the Role of Nutrition and Exercise. Curr Osteoporos Rep 2022; 20:290-308. [PMID: 36044178 PMCID: PMC9522765 DOI: 10.1007/s11914-022-00746-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Impaired recovery following an intensive care unit (ICU) admission is thought related to muscle wasting. Nutrition and physical activity are considered potential avenues to attenuate muscle wasting. The aim of this review was to present evidence for these interventions in attenuating muscle loss or improving strength and function. RECENT FINDINGS Randomised controlled trials on the impact of nutrition or physical activity interventions in critically ill adult patients on muscle mass, strength or function are presented. No nutrition intervention has shown an effect on strength or function, and the effect on muscle mass is conflicting. RCTs on the effect of physical activity demonstrate conflicting results; yet, there is a signal for improved strength and function with higher levels of physical activity, particularly when commenced early. Further research is needed to elucidate the impact of nutrition and physical activity on muscle mass, strength and function, particularly in combination.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
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