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Kim J, Shim Y, Choo YH, Kim HS, Kim YR, Ha EJ. Protein Requirement Changes According to the Treatment Application in Neurocritical Patients. J Korean Neurosurg Soc 2024; 67:451-457. [PMID: 37984964 PMCID: PMC11220411 DOI: 10.3340/jkns.2023.0176] [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: 08/25/2023] [Revised: 11/04/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE Exploring protein requirements for critically ill patients has become prominent. On the other hand, considering the significant impact of coma therapy and targeted temperature management (TTM) on the brain as well as systemic metabolisms, protein requirements may plausibly be changed by treatment application. However, there is currently no research on protein requirements following the application of these treatments. Therefore, the aim of this study is to elucidate changes in patients' protein requirements during the application of TTM and coma therapy. METHODS This study is a retrospective analysis of prospectively collected data from March 2019 to May 2022. Among the patients admitted to the intensive care unit, those receiving coma therapy and TTM were included. The patient's treatment period was divided into two phases (phase 1, application and maintenance of coma therapy and TTM; phase 2, tapering and cessation of treatment). In assessing protein requirements, the urine urea nitrogen (UUN) method was employed to estimate the nitrogen balance, offering insight into protein utilization within the body. The patient's protein requirement for each phase was defined as the amount of protein required to achieve a nitrogen balance within ±5, based on the 24-hour collection of UUN. Changes in protein requirements between phases were analyzed. RESULTS Out of 195 patients, 107 patients with a total of 214 UUN values were included. The mean protein requirement for the entire treatment period was 1.84±0.62 g/kg/day, which is higher than the generally recommended protein supply of 1.2 g/kg/day. As the treatment was tapered, there was a statistically significant increase in the protein requirement from 1.49±0.42 to 2.18±0.60 in phase 2 (p<0.001). CONCLUSION Our study revealed a total average protein requirement of 1.84±0.62 g during the treatment period, which falls within the upper range of the preexisting guidelines. Nevertheless, a notable deviation emerged when analyzing the treatment application period separately. Hence, it is recommended to incorporate considerations for the type and timing of treatment, extending beyond the current guideline, which solely accounts for the severity by disease.
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Affiliation(s)
- Jungook Kim
- Department of Traumatology, Gachon University Gil Medical Center, Incheon, Korea
| | - Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | | | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Kangalgil M, Ulusoy H, Ayaz S. Acute Skeletal Muscle Wasting is Associated with Prolonged Hospital Stay in Critical Illness with Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02017-y. [PMID: 38918337 DOI: 10.1007/s12028-024-02017-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/16/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Acute muscle wasting is common in critically ill patients, and this can lead to unfavorable clinical outcomes. The aim of this study was to identify factors associated with muscle wasting and to investigate the association between skeletal muscle wasting and prolonged hospital stay in critically ill patients with acute brain injury. METHODS This single-center prospective observational study was conducted in critically ill patients with acute brain injury who stayed in the intensive care unit for at least 1 week. The rectus femoris cross-sectional area was measured via ultrasound at baseline and a week after the first assessment. Univariate and multivariate logistic regression analyses were performed to identify factors that predicted prolonged hospital stay. RESULTS A total of 86 patients were included in the study. Their mean age was 49.4 ± 16.9 years, 57% were male, and 46.5% had an admission diagnosis of subarachnoid hemorrhage. The percentage change in the rectus femoris cross-sectional area was 15.8% (95% confidence interval [CI] - 19.8% to - 12.0%; p < 0.001), and 57% of all patients had acute muscle wasting. According to the univariate analysis, there was a significant association between prolonged hospital stay and acute muscle wasting (odds ratio [OR] 3.677; 95% CI 1.487-9.043; p = 0.005), mechanical ventilation status (OR 3.600; 95% CI 1.455-8.904; p = 0.006), and Glasgow Coma Scale score (OR 0.888; 95% CI 0.808-0.976; p = 0.014) at intensive care unit admission. The multivariate analysis demonstrated that acute muscle wasting (OR 3.449; 95% CI 1.344-8.853; p = 0.010) was an independent risk factor for prolonged hospital stay. CONCLUSIONS There was considerable muscle wasting in critically ill patients with brain injuries over a 1-week period. Acute muscle wasting was associated with prolonged hospital stay in critically ill patients with acute brain injury.
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Affiliation(s)
- Melda Kangalgil
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Sivas Cumhuriyet University, Sivas, Turkey.
| | - Hülya Ulusoy
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Sekine Ayaz
- Department of Anesthesiology and Reanimation, Pasinler Ibrahim Hakkı State Hospital, Erzurum, Turkey
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Aadal L, Holst M, Poulsen I, Siig M, Odgaard L. Nutritional interventions and related efforts addressing undernutrition during rehabilitation after acquired brain injury: a scoping review protocol. BMJ Open 2024; 14:e080165. [PMID: 38889937 PMCID: PMC11191809 DOI: 10.1136/bmjopen-2023-080165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 05/30/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Patients with an acquired brain injury (ABI) are at an increased risk of undernutrition due to the disease-related inflammation and other numerous symptoms that impact their nutrition. Unfortunately, recommendations related to nutritional interventions and related efforts vary. The objective of this scoping review is to map the body of literature on nutritional interventions and related efforts provided by health professionals, such as screening or assessments, addressing undernutrition in adults with a moderate to severe ABI during the subacute rehabilitation pathway. METHODS AND ANALYSIS The review follows the Joanna Briggs Institute methodology for scoping reviews. The librarian-assisted search strategy will be conducted in the bibliographical databases: MEDLINE (PubMed), Embase, CINAHL, Web of Science and OpenGrey. Indexed and grey literature in English, German or Scandinavian languages from January 2010 will be considered for inclusion. Two independent reviewers will conduct the iterative process of screening the identified literature, paper selection and data extraction. Disagreements will be resolved by discussion until a consensus is reached. A template will be used to guide the data extraction. This scoping review will include research articles, methodological papers and clinical guidelines reporting on nutritional interventions or related efforts to prevent or address undernutrition in adult patients (≥18 years) with moderate to severe ABI within the first year after admission to rehabilitation hospital. We will map all kinds of nutritional efforts provided by professionals in different settings within high-income countries, including interventions targeting relatives. ETHICS AND DISSEMINATION This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. The results will be published in an international peer-reviewed journal, presented at scientific conferences and disseminated through digital science communication platforms. STUDY REGISTRATION Open Science Framework: https://doi.org/10.17605/OSF.IO/H5GJX.
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Affiliation(s)
- Lena Aadal
- Department of Research, Hammel Neurorehabilitation and Research Centre, Hammel, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Holst
- Centre for Nutrition and Intestinal Failure, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ingrid Poulsen
- Department for People and Technology, Roskilde University and Nursing and Health Care, Health, Aarhus University, Amager Hvidovre Hospital, Hvidovre, Denmark
| | - Margrethe Siig
- Health Care, Ringkøbing Skjern Municipality, Ringkøbing, Denmark
| | - Lene Odgaard
- Hammel Neurorehabilitation and Research Centre, Aarhus Universitet, Hammel, Denmark
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Breeding T, Nasef H, Patel H, Awan MU, Chin B, Cruz F, Zito T, Smith CP, Elkbuli A. Clinical Outcomes of Early Versus Late Enteral Nutrition Support in Critically Ill Trauma Patients With Isolated Traumatic Brain Injury. Am Surg 2024; 90:1187-1194. [PMID: 38197391 DOI: 10.1177/00031348241227203] [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: 01/11/2024]
Abstract
INTRODUCTION This study aims to compare the impact of early initiation of enteral feeding initiation on clinical outcomes in critically ill adult trauma patients with isolated traumatic brain injuries (TBI). METHODS A retrospective cohort analysis of the American College of Surgeons Trauma Quality Program Participant Use File 2017-2021 dataset of critically ill adult trauma patients with moderate to severe blunt isolated TBI. Outcomes included ICU length of stay (ICU-LOS), ventilation-free days (VFD), and complication rates. Timing cohorts were defined as very early (<6 hours), early (6-24 hours), intermediate (24-48 hours), and late (>48 hours). RESULTS 9210 patients were included in the analysis, of which 952 were in the very early enteral feeding initiation group, 652 in the early, 695 in intermediate, and 6938 in the late group. Earlier feeding was associated with significantly shorter ICU-LOS (very early: 7.82 days; early: 11.28; intermediate 12.25; late 17.55; P < .001) and more VFDs (very early: 21.72 days; early: 18.81; intermediate 18.81; late 14.51; P < .001). Patients with late EF had a significantly higher risk of VAP than very early (OR .21, CI 0.12-.38, P < .001) or early EF (OR .33, CI 0.17-.65, P = .001), and higher risk of ARDS than the intermediate group (OR .23, CI 0.05-.925, P = .039). CONCLUSION Early enteral feeding in critically ill adult trauma patients with moderate to severe isolated TBI resulted in significantly fewer days in the ICU, more ventilation-free days, and lower odds of VAP and ARDS the sooner enteral feeding was initiated, with the most optimized outcomes within 6 hours.
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Affiliation(s)
- Tessa Breeding
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Hazem Nasef
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Heli Patel
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Muhammad Usman Awan
- NOVA Southeastern University, Kiran Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Brian Chin
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Francis Cruz
- University of Alabama School of Medicine, Birmingham, AL, USA
| | - Tracy Zito
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Chadwick P Smith
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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El Baassiri MG, Raouf Z, Badin S, Escobosa A, Sodhi CP, Nasr IW. Dysregulated brain-gut axis in the setting of traumatic brain injury: review of mechanisms and anti-inflammatory pharmacotherapies. J Neuroinflammation 2024; 21:124. [PMID: 38730498 PMCID: PMC11083845 DOI: 10.1186/s12974-024-03118-3] [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: 02/29/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Traumatic brain injury (TBI) is a chronic and debilitating disease, associated with a high risk of psychiatric and neurodegenerative diseases. Despite significant advancements in improving outcomes, the lack of effective treatments underscore the urgent need for innovative therapeutic strategies. The brain-gut axis has emerged as a crucial bidirectional pathway connecting the brain and the gastrointestinal (GI) system through an intricate network of neuronal, hormonal, and immunological pathways. Four main pathways are primarily implicated in this crosstalk, including the systemic immune system, autonomic and enteric nervous systems, neuroendocrine system, and microbiome. TBI induces profound changes in the gut, initiating an unrestrained vicious cycle that exacerbates brain injury through the brain-gut axis. Alterations in the gut include mucosal damage associated with the malabsorption of nutrients/electrolytes, disintegration of the intestinal barrier, increased infiltration of systemic immune cells, dysmotility, dysbiosis, enteroendocrine cell (EEC) dysfunction and disruption in the enteric nervous system (ENS) and autonomic nervous system (ANS). Collectively, these changes further contribute to brain neuroinflammation and neurodegeneration via the gut-brain axis. In this review article, we elucidate the roles of various anti-inflammatory pharmacotherapies capable of attenuating the dysregulated inflammatory response along the brain-gut axis in TBI. These agents include hormones such as serotonin, ghrelin, and progesterone, ANS regulators such as beta-blockers, lipid-lowering drugs like statins, and intestinal flora modulators such as probiotics and antibiotics. They attenuate neuroinflammation by targeting distinct inflammatory pathways in both the brain and the gut post-TBI. These therapeutic agents exhibit promising potential in mitigating inflammation along the brain-gut axis and enhancing neurocognitive outcomes for TBI patients.
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Affiliation(s)
- Mahmoud G El Baassiri
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Zachariah Raouf
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Sarah Badin
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Alejandro Escobosa
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Chhinder P Sodhi
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Isam W Nasr
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
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Chen J, Ye B, Lin F, Cai W, Chen R, Ruan Z. An effective insulin infusion protocol for severe traumatic brain injury patients: A retrospective observational study. ENDOCRINOL DIAB NUTR 2024; 71:103-109. [PMID: 38555106 DOI: 10.1016/j.endien.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE Severe traumatic brain injury (sTBI) patients often experience stress hyperglycaemia, which can lead to negative outcomes. This study aims to introduce an effective insulin infusion protocol specifically designed for sTBI patients. METHODS Data was collected from all sTBI patients during two periods: 1 October 2019 to 30 April 2020, and 1 June 2020 to 31 December 2020. In May 2020, a new insulin infusion protocol was implemented. Blood glucose management, infection, coagulation, and prognosis were compared in these two periods. RESULT 195 patients were included, with 106 using the new protocol. The proportion of hyperglycaemia decreased from 40.04% to 26.91% (P<0.05), and the proportion of on-target blood glucose levels increased from 35.69% to 38.98% (P<0.05). Average blood glucose levels decreased from 9.98±2.79mmol/L to 8.96±2.82mmol/L (P<0.05). There was no substantial increase in hypoglycaemia, which remained controlled below 1%. The new protocol positively influenced glucose concentration and dispersion trends. There were no significant differences in catheter-related infections, antibiotic use, mechanical ventilation (MV) duration, length of stay in ICU, Glasgow Outcome Scale (GOS), or mortality. However, the conventional protocol group had a higher coagulation tendency (R-value of thromboelastography 4.80±1.35min vs. 5.52±1.87min, P<0.05), with no difference in deep vein thrombosis (DVT) incidence. CONCLUSION Our findings suggest that a customized insulin infusion process for sTBI patients can effectively manage blood glucose. While there is no significant improvement in infection control or prognosis, it may have a positive impact on coagulation without affecting the occurrence of DVT.
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Affiliation(s)
- Jie Chen
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Bingbing Ye
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Feng Lin
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Wenchao Cai
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China
| | - Rui Chen
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China.
| | - Zhanwei Ruan
- Department of Emergency, Third Affiliated Hospital, Wenzhou Medical University, 108 Wansong Road, Zhejiang 325200, China.
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Tóth B, Dénes Z, Németh M, Fazekas G. Changes in skeletal muscle mass index and fat mass index during rehabilitation for traumatic brain injury and stroke measured by bioelectrical impedance analysis. Int J Rehabil Res 2023; 46:264-269. [PMID: 37334827 DOI: 10.1097/mrr.0000000000000587] [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: 06/21/2023]
Abstract
Although malnutrition may negatively impact the outcomes of rehabilitation and increase the cost of care, there are still no valid nutritional assessment methods appropriate for specific groups of patients undergoing rehabilitation. This study aimed to determine if a multifrequency bioelectrical impedance is suitable for monitoring the changes in body composition of brain-injured patients for whom individualized nutritional goals were set during rehabilitation. Fat mass index (FMI) and skeletal muscle mass index (SMMI) were examined by Seca mBCA515 or portable Seca mBCA525 device within 48 h of admission and before discharge in 11 traumatic brain injury (TBI) and 11 stroke patients with admission Nutritional Risk Screening 2002 scores ≥2. The changes in outcomes and plausible interactions were examined between the admission values and the values estimated for the 18th day (minimum length of stay in the sample) using a repeated measure mixed-sample analysis of covariance. In patients with low FMI at admission (mainly younger, TBI patients, with longer ICU stay), there was no change over time whereas, in those with high admission FMI (older, stroke patients, with shorter ICU stay), a decrease was observed (significant interaction F(1,19) = 9.224 P = 0.007 Part. η² = 0.327). The SMMI significantly increased over time (F(1,19) = 5.202 P = 0.034 Part. η² = 0.215) independently of gender, age, days spent in ICU and cause of brain injury. Our results suggest that bioelectrical impedance analysis is feasible and informative for monitoring the changes in body composition during rehabilitation, which also requires consideration of demographic and pre-rehabilitation characteristics.
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Affiliation(s)
- Babett Tóth
- Rehabilitation Department of Brain injuries, Department for Rehabilitation post Stroke, Department of Alimentation and Dietetics, National Institute of Locomotor Diseases and Disabilities/National Institute for Medical Rehabilitation
| | - Zoltán Dénes
- Rehabilitation Department of Brain injuries, Department for Rehabilitation post Stroke, Department of Alimentation and Dietetics, National Institute of Locomotor Diseases and Disabilities/National Institute for Medical Rehabilitation
- Department of Rehabilitation Medicine, Semmelweis University, Budapest
| | - Mariann Németh
- Rehabilitation Department of Brain injuries, Department for Rehabilitation post Stroke, Department of Alimentation and Dietetics, National Institute of Locomotor Diseases and Disabilities/National Institute for Medical Rehabilitation
- Department of Rehabilitation Medicine, Semmelweis University, Budapest
| | - Gábor Fazekas
- Rehabilitation Department of Brain injuries, Department for Rehabilitation post Stroke, Department of Alimentation and Dietetics, National Institute of Locomotor Diseases and Disabilities/National Institute for Medical Rehabilitation
- University of Szeged, Szeged, Hungary
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