1
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Aljeaidi M, Fiorilla XM, Mammana B, Anstey M. Mucosal bleeding while on venovenous extracorporeal membrane oxygenation in the setting of vitamin C deficiency. BMJ Case Rep 2024; 17:e259185. [PMID: 38926124 DOI: 10.1136/bcr-2023-259185] [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: 06/28/2024] Open
Abstract
A major complication with extracorporeal membrane oxygenation (ECMO) is bleeding which can occur in up to 40% of cases and can be life-threatening. Minor bleeding may be overlooked and under-reported. While some of the underlying mechanisms such as platelet injury and anticoagulation therapy have been identified, several other factors are still under-researched. Here, we describe a unique case of a subtle mucosal membrane bleeding that is found to be associated with vitamin C deficiency while on treatment with ECMO. Investigating vitamin C levels may be useful in understanding causes of bleeding in some patients on ECMO therapy, particularly if there are risk factors for malnutrition.
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Affiliation(s)
- Muhamad Aljeaidi
- The University of Western Australia Medical School, Perth, Western Australia, Australia
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | | | - Bianca Mammana
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Matthew Anstey
- Intensive Care, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- The University of Western Australia Medical School, Nedlands, Western Australia, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
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2
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Zhang H, Zhao L, Jia B. Research progress on nutritional support in the neonatal and pediatric populations receiving extracorporeal membrane oxygenation. Front Nutr 2024; 11:1370286. [PMID: 38887500 PMCID: PMC11180743 DOI: 10.3389/fnut.2024.1370286] [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: 01/14/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024] Open
Abstract
Nutritional support is crucial for the prognosis of children supported by extracorporeal membrane oxygenation (ECMO). This article discusses the latest research progress and guideline recommendations for nutritional support during ECMO. We summarize the nutritional status and evaluation of ECMO patients, nutritional support methods and timing, trace elements, the impact of continuous renal replacement therapy (CRRT), and energy requirements and algorithms. The article shows that malnutrition is high in ECMO patients compared to other critically ill patients, with nearly one-third of patients experiencing a decrease in nutritional indicators. The timing of the initiation of nutrition is very important for the nutritional status of the child. Early enteral nutrition can improve patient prognosis, which is the most commonly used, with parenteral nutrition as a supplement. However, the proportion of enteral nutrition is relatively low, and a stepwise nutrition algorithm can determine when to initiate early enteral nutrition and parenteral nutrition. Malnourishment during critical illness have been associated with increased morbidity as well as increased mortality. Nutritional status should be evaluated at admission by screening tools. In addition, changes in the levels of several metabolites in vivo, such as blood lipids, carnitine, and thiamine, can also reflect the degree of nutritional deficiency in critically ill children. This article provides a reference for the implementation of nutrition of pediatric ECMO patients and further research on nutritional support.
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Affiliation(s)
- Hongquan Zhang
- Zhengzhou Railway Vocational and Technical College, Zhengzhou, Henan Province, China
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lizhuo Zhao
- Department of Pediatric ICU, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, China
| | - Baohui Jia
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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3
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Dresen E, Modir R, Stoppe C. Nutrition support for patients on mechanical circulatory support. Curr Opin Anaesthesiol 2024; 37:24-34. [PMID: 37865830 DOI: 10.1097/aco.0000000000001323] [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: 10/23/2023]
Abstract
PURPOSE OF REVIEW No specific guidelines on medical nutrition therapy (MNT) in patients on different types of mechanical circulatory support (MCS) devices yet exist and overall evidence is limited. The purpose of this narrative review is to provide an overview about current existing evidence, which might be of underrecognized importance for the patients' short-term and long-term clinical and functional outcomes. RECENT FINDINGS Patients on MCS inherit substantial metabolic, endocrinologic, inflammatory, and immunologic alterations, and together with the specificities of MCS therapy, technical modalities of respective devices, and concomitant medication, the consideration of individualized MNT approaches is indicated in routine clinical practice. Exemplarily, the evaluation of the patients' individual nutrition status, determination of nutrition targets, progressive increase of energy and protein supply throughout the different phases of disease, prevention of micronutrient deficiencies, implementation of nutrition protocols, appropriate monitoring strategies, and continuous quality improvement are essential elements of MNT in patients on MCS. SUMMARY The importance of MNT for patients on MCS still often remains underrecognized, which might be of particular relevance in view of the significant metabolic alterations, the long treatment period, and severity of illness in these patients. Further research on more targeted MNT approaches in those patients is urgently needed for the generation of evidence-based guidelines for this specific cohort of critically ill patients.
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Affiliation(s)
- Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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4
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Elke G, Hartl WH, Adolph M, Angstwurm M, Brunkhorst FM, Edel A, Heer GD, Felbinger TW, Goeters C, Hill A, Kreymann KG, Mayer K, Ockenga J, Petros S, Rümelin A, Schaller SJ, Schneider A, Stoppe C, Weimann A. [Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2023; 118:1-13. [PMID: 37067563 PMCID: PMC10106891 DOI: 10.1007/s00063-023-01001-2] [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] [Accepted: 02/23/2023] [Indexed: 04/18/2023]
Abstract
This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.
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Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 Haus R3, 24105, Kiel, Deutschland.
| | - Wolfgang H Hartl
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Großhadern, München, Deutschland
| | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Matthias Angstwurm
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Innenstadt, München, Deutschland
| | - Frank M Brunkhorst
- Zentrum für Klinische Studien, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Deutschland
| | - Andreas Edel
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas W Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching und Neuperlach, Städtisches Klinikum München GmbH, München, Deutschland
| | - Christiane Goeters
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster, Deutschland
| | - Aileen Hill
- Kliniken für Anästhesiologie und Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland
| | | | - Konstantin Mayer
- Klinik für Pneumologie und Schlafmedizin, St. Vincentius-Kliniken, Karlsruhe, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte, Bremen, Deutschland
| | - Sirak Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Andreas Rümelin
- Anästhesie, Intensivmedizin und Notfallmedizin, Helios St. Elisabeth-Krankenhaus Bad Kissingen, Kissingen, Deutschland
| | - Stefan J Schaller
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Medizinische Fakultät, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
| | - Andrea Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Christian Stoppe
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Arved Weimann
- Abteilung für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Leipzig, Deutschland
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5
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Schneeweiss-Gleixner M, Scheiner B, Semmler G, Maleczek M, Laxar D, Hintersteininger M, Hermann M, Hermann A, Buchtele N, Schaden E, Staudinger T, Zauner C. Inadequate Energy Delivery Is Frequent among COVID-19 Patients Requiring ECMO Support and Associated with Increased ICU Mortality. Nutrients 2023; 15:2098. [PMID: 37432241 DOI: 10.3390/nu15092098] [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: 04/07/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) patients during ECMO therapy. METHODS We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses. RESULTS Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372, p = 0.007). CONCLUSIONS Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.
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Affiliation(s)
- Mathias Schneeweiss-Gleixner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Bernhard Scheiner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Semmler
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Laxar
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Marlene Hintersteininger
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Martina Hermann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexander Hermann
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Nina Buchtele
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Christian Zauner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
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Dresen E, Naidoo O, Hill A, Elke G, Lindner M, Jonckheer J, De Waele E, Meybohm P, Modir R, Patel JJ, Christopher KB, Stoppe C. Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice. JPEN J Parenter Enteral Nutr 2023; 47:220-235. [PMID: 36495215 DOI: 10.1002/jpen.2467] [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: 06/26/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Omy Naidoo
- Newtricion Wellness Dieticians, PMB Healthcare Centre, Pietermaritzburg, South Africa
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joop Jonckheer
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Vrije Universiteit Brussel, Brussels Health Campus, Jette, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth B Christopher
- Renal Division, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
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7
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Odelli AL, Holyoak A, Yadav S, Page SM, Lindsay D. The effect of cardiopulmonary bypass on blood thiamine concentration and its association with post-operative lactate concentration. J Cardiothorac Surg 2022; 17:260. [PMID: 36207738 PMCID: PMC9541071 DOI: 10.1186/s13019-022-02016-0] [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: 03/04/2022] [Accepted: 09/24/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Cardiothoracic surgery is a large field in Australia, and evidence suggests post-cardiopulmonary bypass (CPB) hyperlactataemia is associated with higher morbidity and mortality. Low thiamine levels are a potentially common yet treatable cause of hyperlactataemia and may occur in the setting of exposure to CPB non-biological material. We hypothesized that cardiopulmonary bypass would result in decreased whole-blood thiamine levels, which may therefore result in increased whole-blood lactate levels in the post-operative period. Methods Adult patients undergoing non-emergent CPB were recruited in a single centre, prospective, analytic observational study at Townsville University Hospital, Australia. The primary outcome was a comparison of pre- and post-CPB thiamine diphosphate level, secondarily aiming to assess any relationship between lactate and thiamine levels. Prospective pre- and post-CPB blood samples were taken and analysed at a central reference laboratory. Results Data was available for analysis on 78 patients. There was a statistically significant increase in thiamine diphosphate level from pre-CPB: 1.36 nmol/g Hb, standard deviation (SD) 0.31, 95% confidence intervals (CI) 1.29–1.43, to post-CPB: 1.77 nmol/g Hb, SD 0.53, 95% CI 1.43–1.88, p value < 0.001. There was a non-statistically significant (p > 0.05) trend in rising whole-blood lactate levels with increasing time. Analysis of lactate levels at varying time periods found a significant difference between baseline measurements and increased levels at 13–16 h (p < 0.05). There was no significant relationship observed between whole-blood thiamine levels and post-operative lactate levels. Conclusion Whole-blood thiamine levels were found to increase immediately post-CPB in those undergoing elective cardiac surgery. There was no correlation between whole-blood thiamine levels and post-operative arterial lactate levels.
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Affiliation(s)
- Andrea L Odelli
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW, 2305, Australia.
| | - Adam Holyoak
- Medical Superintendent, Thursday Island Hospital, Thursday Island, QLD, Australia
| | - Sumit Yadav
- Director of Cardiothoracic Surgery, Townsville University Hospital, Douglas, QLD, Australia
| | - Sarah M Page
- Department of Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
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8
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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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9
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D'Alesio M, Martucci G, Arcadipane A, Lorusso R, Amrein K. Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines. Artif Organs 2022; 46:1240-1248. [PMID: 35230717 DOI: 10.1111/aor.14215] [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: 10/15/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population. METHODS A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective. RESULTS Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day. CONCLUSIONS Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.
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Affiliation(s)
- Mark D'Alesio
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gennaro Martucci
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Antonio Arcadipane
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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10
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Girard L, Djemili F, Devineau M, Gonzalez C, Puech B, Valance D, Renou A, Dubois G, Braunberger E, Allou N, Allyn J, Vidal C. Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock. J Cardiothorac Vasc Anesth 2021; 36:2376-2384. [PMID: 34903457 DOI: 10.1053/j.jvca.2021.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock. DESIGN This was a retrospective and observational study. SETTING University hospital. PARTICIPANTS The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications. CONCLUSION The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.
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Affiliation(s)
- Léandre Girard
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France.
| | - Fares Djemili
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Marjolaine Devineau
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Céline Gonzalez
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Bérénice Puech
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Dorothée Valance
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Amélie Renou
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Gilbert Dubois
- Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Eric Braunberger
- Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Nicolas Allou
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Jérôme Allyn
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Charles Vidal
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
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11
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Toh TSW, Ong C, Mok YH, Mallory P, Cheifetz IM, Lee JH. Nutrition in Pediatric Extracorporeal Membrane Oxygenation: A Narrative Review. Front Nutr 2021; 8:666464. [PMID: 34409059 PMCID: PMC8365758 DOI: 10.3389/fnut.2021.666464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support is increasingly utilized in quaternary pediatric intensive care units. Metabolic derangements and altered nutritional requirements are common in critically ill children supported on ECMO. However, there remains no consensus on the optimal approach to the prescription of nutrition in these patients. This narrative review aims to summarize the current medical literature on various aspects of nutrition support in pediatric patients on ECMO. These include: (1) nutritional adequacy, (2) pros and cons of feeding on ECMO, (3) enteral vs. parenteral nutrition, and (4) proposed recommendations and future directions for research in this area.
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Affiliation(s)
- Theresa S W Toh
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira M Cheifetz
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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12
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Brisard L, Bailly A, Le Thuaut A, Bizouarn P, Lepoivre T, Nicolet J, Roussel JC, Senage T, Rozec B. Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2021; 46:526-537. [PMID: 34166531 DOI: 10.1002/jpen.2209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support. Analysis of nutrition practices could improve nutrition management of this particular population. METHODS A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days. Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome. RESULTS A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections. CONCLUSION EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.
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Affiliation(s)
- Laurent Brisard
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Arthur Bailly
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | | | - Philippe Bizouarn
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Thierry Lepoivre
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Johanna Nicolet
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, PHU 2 Institut du thorax et du système nerveux, CHU Nantes, Nantes, France
| | - Thomas Senage
- Department of Thoracic and Cardiovascular Surgery, PHU 2 Institut du thorax et du système nerveux, CHU Nantes, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, CHU Nantes, Nantes, France
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13
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Influence of the ECMO circuit on the concentration of nutritional supplements. Sci Rep 2020; 10:19275. [PMID: 33159150 PMCID: PMC7648645 DOI: 10.1038/s41598-020-76299-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022] Open
Abstract
Circulating compounds such as drugs and nutritional components might adhere to the oxygenator fibers and tubing during ECMO support. This study evaluated the amount of nutritional supplements adsorbed to the ECMO circuit under controlled ex vivo conditions. Six identical ECMO circuits were primed with fresh human whole blood and maintained under physiological conditions at 36 °C for 24 h. A dose of nutritional supplement calculated for a 70 kg patient was added. 150 mL volume was drawn from the priming bag for control samples and kept under similar conditions. Blood samples were obtained at predetermined time points and analyzed for concentrations of vitamins, minerals, lipids, and proteins. Data were analyzed using mixed models with robust standard errors. No significant differences were found between the ECMO circuits and the controls for any of the measured variables: cobalamin, folate, vitamin A, glucose, minerals, HDL cholesterol, LDL cholesterol, total cholesterol, triglycerides or total proteins. There was an initial decrease and then an increase in the concentration of cobalamin and folate. Vitamin A concentrations decreased in both groups over time. There was a decrease in concentration of glucose and an increased concentration of lactate dehydrogenase over time in both groups. There were no significant alterations in the concentrations of nutritional supplements in an ex vivo ECMO circuit compared to control samples. The time span of this study was limited, thus, clinical studies over a longer period of time are needed.
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14
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Stoppe C, Nesterova E, Elke G. Nutritional support in patients with extracorporeal life support and ventricular assist devices. Curr Opin Crit Care 2019; 24:269-276. [PMID: 29847341 DOI: 10.1097/mcc.0000000000000512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD. RECENT FINDINGS ECLS may aggravate loss of endogenous and exogenous micronutrients and macronutrients. Observational studies have shown that enteral nutrition is feasible and most commonly used in patients with ECLS. Indirect calorimetry may be feasible for measuring energy expenditure during ECLS. Specific tools are available to assess malnutrition or nutrition risk in patients with VAD but require further validation in the perioperative setting. If parenteral nutrition is indicated, the use of intravenous lipid emulsions may be associated with membrane oxygenator dysfunction of the ECLS device or increased infectious risk in patients with VAD. SUMMARY Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Ekaterina Nesterova
- Department of Anesthesiology and Intensive Care Medicine, National Pirogov Surgical Medical Center, Moscow, Russia
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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15
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Burstedt D, Tippett JC. Severe Hypertriglyceridemia During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:3418-3422. [PMID: 31076303 DOI: 10.1053/j.jvca.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 01/04/2023]
Affiliation(s)
- David Burstedt
- Baylor Scott & White Healthcare/Texas A&M University Health Science Center College of Medicine, Temple, TX
| | - J Clint Tippett
- Baylor Scott & White Healthcare/Texas A&M University Health Science Center College of Medicine, Temple, TX.
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16
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Nair P, Venkatesh B, Hoechter DJ, Buscher H, Kerr S, Center JR, Myburgh JA. Vitamin D status and supplementation in adult patients receiving extracorporeal membrane oxygenation. Anaesth Intensive Care 2019; 46:589-595. [PMID: 30447668 DOI: 10.1177/0310057x1804600609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The prevalence of vitamin D deficiency in critical illness is known to be high and associated with adverse clinical outcomes. Patients receiving extracorporeal membrane oxygenation (ECMO) may be at increased risk of vitamin D deficiency due to high severity of acute illness. Challenges with drug dosing in ECMO patients are recognised due to increased volume of distribution and drug absorption to circuit components. To describe the prevalence of vitamin D deficiency in ECMO patients and the effect of intramuscular dosing of cholecalciferol on levels of vitamin D metabolites, and to compare these data with intensive care unit (ICU) patients not receiving ECMO, two prospective studies were performed sequentially: an observational study of 100 consecutive ICU patients and an interventional study assessing effects of intramuscular cholecalciferol in 50 ICU patients. The subgroup of patients who required ECMO support in each of these studies was analysed and compared to patients who did not receive ECMO. Twenty-four ECMO patients, 12 from the observational study and 12 from the interventional study (who received intramuscular cholecalciferol) were studied-21/24 (88%) ECMO patients were vitamin D deficient at baseline compared to 65/126 (52%) of non-ECMO patients (<i>P</i>=0.006). Of the 12 ECMO patients who received cholecalciferol, six patients (50%) achieved correction of deficiency compared to 36/38 (95%) non-ECMO patients (<i>P</i>=0.001). The prevalence of vitamin D deficiency is higher in ECMO patients compared to other critically ill adults. Correction of deficiency with single dose cholecalciferol is not reliable; higher or repeated doses should be considered to correct deficiency.
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Affiliation(s)
- P Nair
- Senior Specialist, Intensive Care Unit, St Vincent's Hospital; University of New South Wales; The George Institute for Global Health; Garvan Institute of Medical Research; Sydney, New South Wales
| | - B Venkatesh
- Pre-eminent specialist, Princess Alexandra Hospital; Professor of Intensive Care, University of Queensland; Brisbane, Queensland; Honorary Professor, University of New South Wales; Professorial Fellow, The George Institute for Global Health; Sydney, New South Wales
| | | | - H Buscher
- Conjoint Senior Lecturer, University of New South Wales; Sydney, New South Wales
| | | | - J R Center
- Professor of Endocrinology, University of New South Wales; Garvan Institute of Medical Research; Sydney, New South Wales
| | - J A Myburgh
- Professor of Intensive Care, University of New South Wales; Senior Specialist, Intensive Care Unit, St George Private Hospital; Sydney, New South Wales
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17
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Vicinanza A, De Laet C, Rooze S, Willems A, Beretta-Piccoli X, Vens D, Voglet C, Jacquemart C, Massin M, Biarent D. Shoshin Beriberi and Severe Accidental Hypothermia as Causes of Heart Failure in a 6-Year-Old Child: A Case Report and Brief Review of Literature. Front Pediatr 2019; 7:119. [PMID: 30984730 PMCID: PMC6449648 DOI: 10.3389/fped.2019.00119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/11/2019] [Indexed: 01/01/2023] Open
Abstract
Severe accidental hypothermia has been demonstrated to affect ventricular systolic and diastolic functions, and rewarming might be responsible of cardiovascular collapse. Until now, there have been only a few reports on severe accidental hypothermia, none of which involved children. Herein, we describe here a rare case of heart failure in a 6-year-old boy admitted to the emergency unit owing to severe hypothermia and malnutrition. After he was warmed up (core temperature of 27.2°C at admission), he developed cardiac arrest, requiring vasoactive amines administration, and veno-arterial extracorporeal membrane oxygenation. Malnutrition and refeeding syndrome might have caused the thiamine deficiency, commonly known as beriberi, which contributed to heart failure as well. He showed remarkable improvement in heart failure symptoms after thiamine supplementation. High-dose supplementation per os (500 mg/day) after reconstitution of an adequate electrolyte balance enabled the patient to recover completely within 2 weeks, even if a mild diastolic cardiac dysfunction persisted longer. In conclusion, we describe an original pediatric case of heart failure due to overlap of severe accidental hypothermia with rewarming, malnutrition, and refeeding syndrome with thiamine deficiency, which are rare independent causes of cardiac dysfunction. The possibility of beriberi as a cause of heart failure and adequate thiamine supplementation should be considered in all high-risk patients, especially those with malnutrition. Refeeding syndrome requires careful management, including gradual electrolyte imbalance correction and administration of a thiamine loading dose to prevent or correct refeeding-induced thiamine deficiency.
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Affiliation(s)
- Alfredo Vicinanza
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Corinne De Laet
- Nutrition and Metabolic Unit, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Shancy Rooze
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Ariane Willems
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Xavier Beretta-Piccoli
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Daphné Vens
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Cédric Voglet
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Jacquemart
- Division of Pediatric Cardiology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Martial Massin
- Division of Pediatric Cardiology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Dominique Biarent
- Pediatric Intensive Care Department, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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18
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Pelekhaty S, Galvagno SM, Hochberg E, Herr DL, Lantry JH, Kon ZN, Deatrick KB, Menaker J. Nitrogen Balance During Venovenous Extracorporeal Membrane Oxygenation Support: Preliminary Results of a Prospective, Observational Study. JPEN J Parenter Enteral Nutr 2018; 44:548-553. [PMID: 29799136 DOI: 10.1002/jpen.1176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Current literature is insufficient to support specific guidelines for estimating nutrition needs during extracorporeal membrane oxygenation (ECMO). The purpose of this single-center observational study was to investigate protein catabolism during venovenous (VV) ECMO support and assess whether current nutrition recommendations were adequate. METHODS All patients admitted to the Lung Rescue Unit between November 2016 and June 2017 were screened for eligibility. Patients with a documented nitrogen balance (NB) study were included in the data set. NB results were excluded for a change in blood urea nitrogen ≥10 mg/dL during the urine collection or unquantified nitrogen losses. Demographics, ECMO-specific data, NB, nutrition prescription, and infusion were recorded in a prospective, observational manner. RESULTS After exclusions, 25 NB results in 16 patients were included for analysis. Nonobese (body mass index [BMI] ˂ 30 kg/m2 ) and obese (BMI ≥ 30 kg/m2 ) patients received 85% and 84% of their prescribed protein, respectively. Nonobese patients had a mean NB of -1.7 ± 5.7, whereas obese patients had a mean NB of -11.5 ± 9.6. Obese patients displayed significantly higher urine urea nitrogen (26.7 ± 7.7 vs 13.5 ± 4.3; P = .00004). CONCLUSIONS These preliminary findings suggest that current guidelines for estimating protein needs in critically ill patients may be adequate for nonobese patients receiving VV ECMO. However, current protein recommendations for critically ill obese patients may not be adequate during VV ECMO support, possibly related to significantly higher rates of catabolism. Future studies with a larger cohort of patients are needed to confirm these results.
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Affiliation(s)
- Stacy Pelekhaty
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Eric Hochberg
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Daniel L Herr
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James H Lantry
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zachary N Kon
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kristopher B Deatrick
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jay Menaker
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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