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Edwards MGP, Andersen JR, Curtis DJ, Riberholt CG, Poulsen I. Diet-induced ketosis in adult patients with subacute acquired brain injury: a feasibility study. Front Med (Lausanne) 2024; 10:1305888. [PMID: 38571572 PMCID: PMC10990248 DOI: 10.3389/fmed.2023.1305888] [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: 10/02/2023] [Accepted: 11/23/2023] [Indexed: 04/05/2024] Open
Abstract
Background Research in animal models on cerebral metabolism after brain injury highlights the potential benefits of ketosis in reducing secondary brain injury, but studies in humans are lacking. Aim This study aimed to examine if a 6-week ketogenic diet intervention with added medium-chain triglycerides (MCT) was feasible in adult patients with acquired brain injury in the subacute phase, whether ketosis could be achieved and maintained, and to what extent serious adverse reactions, adverse reactions, serious adverse events, and adverse events occured. Methods Patients ≥18 years of age diagnosed with subacute acquired brain injury and an expectation of hospitalisation ≥6 weeks were included in the intervention group. Patients not included in the intervention group were included in a standard care reference group. The intervention consisted of a ketogenic diet supplemented with MCT to obtain a plasma concentration of β-hydroxybutyrate (BHB) ≥0.5 mmol/L. Patients who were enterally fed were given KetoCal® 2.5:1 LQ MCT Multi Fiber (Nutricia A/S, Allerød, Denmark), supplemented with Liquigen® (Nutricia A/S, Allerød, Denmark). Patients consuming oral nutrition were given KetoCal® 2.5:1 LQ MCT Multi Fiber supplemented with Liquigen®, in addition to ketogenic meals. Results During a 13-week inclusion period, 12 of 13 eligible patients (92% [95% CI: 67% to 99%]) were included in the intervention group, and 17 of 18 excluded patients (94% [95% CI: 74% to 99%]) were included in the reference group. Eight patients (67%) completed the 6-week intervention. It took a median of 1 day to achieve ketosis from starting a 100% MCT ketogenic diet, and it was maintained for 97% of the intervention period after ketosis was obtained. There were no serious adverse reactions to the MCT ketogenic diet, and patients experienced adverse reactions not considered serious in 9.5% of days with the intervention. The MCT ketogenic diet was accepted by patients on all intervention days, and in the two patients transitioning from enteral feeding to oral intake, there were no complications related to transitioning. Conclusion Intervention with MCT ketogenic diet is feasible and tolerated for 6 weeks in hospitalised adult patients with subacute acquired brain injury. Randomised controlled trials are needed to assess the benefits and harms of the MCT ketogenic diet and the effect on patients' recovery.Clinical trial registration: ClinicalTrials.gov, identifier [NCT04308577].
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Affiliation(s)
- Maria G. P. Edwards
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Jens R. Andersen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Derek J. Curtis
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Christian G. Riberholt
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
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Ni C, Liu L, Tao T, Zhao J, Cao Z, Cheng C. Clinical value of bedside ultrasound measurements of inferior vena cava diameter and its rate of change in early fluid resuscitation in patients with severe traumatic brain injury. Am J Transl Res 2022; 14:6991-7001. [PMID: 36398271 PMCID: PMC9641456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/14/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To explore the clinical value of inferior vena cava diameter (IVCD) detection in guiding early fluid resuscitation in patients with severe traumatic brain injury (sTBI). METHODS Eighty patients with sTBI admitted to our hospital from October 2018 to October 2021 were retrospectively enrolled and divided into an observation group (n=40) and control group (n=40) according to the different monitoring methods used for treatment. The cerebrospinal fluid (CSF) lactate level, coagulation function, neurological function, and functional impairment, organ, cognitive, living ability and physical condition, Glasgow score, and adverse reactions in two groups were compared. RESULTS The differences in CSF lactate level and serum levels of PT, APTT and TT between both groups before resuscitation were not significant (all P>0.05). After resuscitation, all these indexes decreased in both groups, so that patients in the observation group had significantly lower CSF lactate level and serum levels of PT, APTT and TT than those in the control group (all P<0.05). Differences in the levels of neurological function factors such as GFAP, NSE, MBP, and S-100B and the scores of NIHSS, SOFA, MMSE, APACHE II and Barthel were not significant between both groups before treatment (all P>0.05). The levels of neurological function factors, NIHSS, SOFA and APACHE II scores decreased in both groups after treatment (all P<0.05) with lower scores in the observation group than the control group (all P<0.05). The MMSE and Barthel scores increased after treatment, and the scores were significantly higher in the observation group than those in the control group (all P<0.05). The GOS scores of patients in the observation group were higher than those in the control group at 1 month after treatment. The incidence of adverse reactions in the observation group (10%) was significantly lower than in the control group (30%). CONCLUSION Monitoring IVCD to guide fluid resuscitation in patients with sTBI can reduce cerebrospinal fluid lactate levels, better protect patients' vital organs and neurological function, reduce the occurrence of adverse effects, improve patients' quality of life, and improve prognostic outcome.
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Affiliation(s)
- Chunhua Ni
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
| | - Long Liu
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
| | - Tao Tao
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
| | - Jin Zhao
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
| | - Zeng Cao
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
| | - Chao Cheng
- Intensive Care Unit, The Affiliated Kunshan Hospital of Jiangsu University Kunshan 215300, Jiangsu, China
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Statistical analysis plan: Early mobilization by head-up tilt with stepping versus standard care after severe traumatic brain injury. Contemp Clin Trials Commun 2021; 24:100856. [PMID: 34877432 PMCID: PMC8628210 DOI: 10.1016/j.conctc.2021.100856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 09/12/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022] Open
Abstract
Background Early mobilization on a tilt table with stepping versus standard care may be beneficial for patients with severe brain injury, but data from randomized clinical trials are lacking. This detailed statistical analysis plan describes the analyses of data collected in a randomized clinical feasibility trial for early mobilization by head-up tilt with stepping versus standard care after severe traumatic brain injury. Methods Primary feasibility outcomes are the proportion of included participants who were randomized out of all screened patients; the proportion of participants allocated to the experimental intervention who received at least 60% of the planned exercise sessions; and safety outcomes such as adverse events and reactions and serious adverse events and reactions. Exploratory clinical outcomes are suspected unexpected serious adverse reactions; and functional outcomes as assessed by the Coma Recovery Scale-Revised at four weeks; Early Functional Ability Scale and Functional Independence Measure at three months. The description includes the statistical analysis plan, including the use of multiple imputations and Trial Sequential Analysis.
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Key Words
- 95% CI, 95% confidence interval
- AE, adverse event
- AR, adverse reaction
- CG, Control group
- CRS-R, Coma Recovery Scale-Revised
- EFA, Early Functional Ability
- EOE, Early orthostatic exercise
- Early mobilization
- FIM, Functional Independence Measure
- GCS, Glasgow coma scale
- ICU, Intensive care unit
- SAE, serious adverse event
- SAR, serious adverse reaction
- SD, standard deviation
- SUSAR, suspected unexpected adverse reaction
- Statistical analysis plan
- Traumatic brain injury
- Trial sequential analysis
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Dynamic cerebral autoregulation during early orthostatic exercise in patients with severe traumatic brain injury: Further exploratory analyses from a randomized clinical feasibility trial. J Clin Neurosci 2021; 92:39-44. [PMID: 34509259 DOI: 10.1016/j.jocn.2021.07.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/25/2021] [Accepted: 07/25/2021] [Indexed: 01/10/2023]
Abstract
In patients with severe traumatic brain injury, there is limited evidence of the clinical effect of early orthostatic exercise, although such exercise may strengthen systemic or cerebral hemodynamic responses to head-up tilt, thereby minimizing orthostatic intolerance. We measured dynamic cerebral autoregulation (dCA) and the occurrence of orthostatic intolerance after four weeks of regular orthostatic exercise by head-up tilt using a tilt table with integrated stepping using the ERIGO® tilt-table and comparing it to standard care. Thirty-four patients with severe traumatic brain injury admitted to a neurocritical care unit were included in this randomized clinical trial. Middle cerebral artery blood flow velocity (MCAv), non-invasive mean arterial pressure, heart rate and PaCO2 were recorded; dCA was measured by the non-invasive mean flow index (nMxa). Transition from the supine position to head-up tilt triggered a 10-16% decrease in MCAv and increased nMxa in both groups at all time points (P < 0.05), with no differences between groups. There was no difference in the number of episodes with orthostatic intolerance (5 vs 3; 1 vs 2; 1 vs 0) at baseline, two weeks and four weeks, respectively, and no association between changes in PaCO2-adjusted nMxa and the occurrence of orthostatic reactions (P = 0.35). Early orthostatic exercise does not affect dynamic cerebral autoregulation and does not protect against orthostatic intolerance in patients with severe traumatic brain injury. Trial registration: ClinicalTrials.gov identifier: NCT02924649. Registered on 3rd October 2016.
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Riberholt CG, Olsen MH, Søndergaard CB, Gluud C, Ovesen C, Jakobsen JC, Mehlsen J, Møller K. Early Orthostatic Exercise by Head-Up Tilt With Stepping vs. Standard Care After Severe Traumatic Brain Injury Is Feasible. Front Neurol 2021; 12:626014. [PMID: 33935935 PMCID: PMC8079637 DOI: 10.3389/fneur.2021.626014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Intensive rehabilitation of patients after severe traumatic brain injury aims to improve functional outcome. The effect of initiating rehabilitation in the early phase, in the form of head-up mobilization, is unclear. Objective: To assess whether early mobilization is feasible and safe in patients with traumatic brain injury admitted to a neurointensive care unit. Methods: This was a randomized parallel-group clinical trial, including patients with severe traumatic brain injury (Glasgow coma scale <11 and admission to the neurointensive care unit). The intervention consisted of daily mobilization on a tilt-table for 4 weeks. The control group received standard care. Outcomes were the number of included participants relative to all patients with traumatic brain injury who were approached for inclusion, the number of conducted mobilization sessions relative to all planned sessions, as well as adverse events and reactions. Information on clinical outcome was collected for exploratory purposes. Results: Thirty-eight participants were included (19 in each group), corresponding to 76% of all approached patients [95% confidence interval (CI) 63–86%]. In the intervention group, 74% [95% CI 52–89%] of planned sessions were carried out. There was no difference in the number of adverse events, serious adverse events, or adverse reactions between the groups. Conclusions: Early head-up mobilization is feasible in patients with severe traumatic brain injury. Larger randomized clinical trials are needed to explore potential benefits and harms of such an intervention. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02924649]. Registered on 3rd October 2016.
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Affiliation(s)
- Christian Gunge Riberholt
- Traumatic Brain Injury Unit, Department of Neurorehabilitation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Gluud
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Ovesen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Neurology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Hernandez S, Kittelty K, Hodgson CL. Rehabilitating the neurological patient in the ICU: what is important? Curr Opin Crit Care 2021; 27:120-130. [PMID: 33395083 DOI: 10.1097/mcc.0000000000000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients. RECENT FINDINGS There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU. SUMMARY Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.
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Affiliation(s)
- Sabrina Hernandez
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Discipline of Physiotherapy, Department of Allied Health, The Royal Melbourne Hospital
| | - Katherine Kittelty
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
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