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Brunker LB, Boncyk CS, Rengel KF, Hughes CG. Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges. Clin Interv Aging 2023; 18:93-112. [PMID: 36714685 PMCID: PMC9879046 DOI: 10.2147/cia.s365968] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/12/2023] [Indexed: 01/23/2023] Open
Abstract
There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.
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Affiliation(s)
- Lucille B Brunker
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly F Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Koelfat KV, Picot D, Chang X, Desille‐Dugast M, van Eijk HM, van Kuijk SM, Lenicek M, Layec S, Carsin M, Dussaulx L, Seynhaeve E, Trivin F, Lacaze L, Thibault R, Schaap FG, Olde Damink SW. Chyme Reinfusion Restores the Regulatory Bile Salt-FGF19 Axis in Patients With Intestinal Failure. Hepatology 2021; 74:2670-2683. [PMID: 34133768 PMCID: PMC8596508 DOI: 10.1002/hep.32017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 04/20/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Automated chyme reinfusion (CR) in patients with intestinal failure (IF) and a temporary double enterostomy (TDE) restores intestinal function and protects against liver injury, but the mechanisms are incompletely understood. The aim was to investigate whether the beneficial effects of CR relate to functional recovery of enterohepatic signaling through the bile salt-FGF19 axis. APPROACH AND RESULTS Blood samples were collected from 12 patients, 3 days before, at start, and 1, 3, 5, and 7 weeks after CR initiation. Plasma FGF19, total bile salts (TBS), 7-α-hydroxy-4-cholesten-3-one (C4; a marker of bile salt synthesis), citrulline (CIT), bile salt composition, liver tests, and nutritional risk indices were determined. Paired small bowel biopsies prior to CR and after 21 days were taken, and genes related to bile salt homeostasis and enterocyte function were assessed. CR induced an increase in plasma FGF19 and decreased C4 levels, indicating restored regulation of bile salt synthesis through endocrine FGF19 action. TBS remained unaltered during CR. Intestinal farnesoid X receptor was up-regulated after 21 days of CR. Secondary and deconjugated bile salt fractions were increased after CR, reflecting restored microbial metabolism of host bile salts. Furthermore, CIT and albumin levels gradually rose after CR, while abnormal serum liver tests normalized after CR, indicating restored intestinal function, improved nutritional status, and amelioration of liver injury. CR increased gene transcripts related to enterocyte number, carbohydrate handling, and bile salt homeostasis. Finally, the reciprocal FGF19/C4 response after 7 days predicted the plasma CIT time course. CONCLUSIONS CR in patients with IF-TDE restored bile salt-FGF19 signaling and improved gut-liver function. Beneficial effects of CR are partly mediated by recovery of the bile salt-FGF19 axis and subsequent homeostatic regulation of bile salt synthesis.
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Affiliation(s)
- Kiran V.K. Koelfat
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands,NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
| | - Denis Picot
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Xinwei Chang
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands,NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
| | - Mireille Desille‐Dugast
- INSERM, INRAEUniversity of RennesNutrition Metabolisms and CancerNuMeCanNutrition UnitCRB SantéCHU RennesRennesFrance
| | - Hans M. van Eijk
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands,NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
| | - Sander M.J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Martin Lenicek
- Institute of Medical Biochemistry and Laboratory Diagnostics1st Faculty of MedicineCharles UniversityPragueCzech Republic
| | - Sabrina Layec
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Marie Carsin
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Laurence Dussaulx
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Eloi Seynhaeve
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Florence Trivin
- Department of Nutritional and Digestive RehabilitationClinique Saint YvesRennesFrance
| | - Laurence Lacaze
- INSERM, INRAEUniversity of RennesNutrition Metabolisms and CancerNuMeCanNutrition UnitCRB SantéCHU RennesRennesFrance
| | - Ronan Thibault
- INSERM, INRAEUniversity of RennesNutrition Metabolisms and CancerNuMeCanNutrition UnitCRB SantéCHU RennesRennesFrance
| | - Frank G. Schaap
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands,NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands,Department of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
| | - Steven W.M. Olde Damink
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands,NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands,Department of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
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Abstract
Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.
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Bharadwaj S, Meka K, Tandon P, Rathur A, Rivas JM, Vallabh H, Jevenn A, Guirguis J, Sunesara I, Nischnick A, Ukleja A. Management of gastroparesis-associated malnutrition. J Dig Dis 2016; 17:285-94. [PMID: 27111029 DOI: 10.1111/1751-2980.12344] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/07/2016] [Accepted: 03/24/2016] [Indexed: 12/11/2022]
Abstract
Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re-evaluation and enteral and parental nutrition should be considered in complex GP patients.
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Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Krishna Meka
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - Parul Tandon
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - Abdullah Rathur
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - John M Rivas
- Department of Gastroenterology/Hepatology, Cleveland Clinic, West Palm Beach, Florida, USA
| | - Hiren Vallabh
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Andrea Jevenn
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - John Guirguis
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Imran Sunesara
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Amy Nischnick
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Andrew Ukleja
- Department of Gastroenterology/Hepatology, Cleveland Clinic, West Palm Beach, Florida, USA
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