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Viner Smith E, Kouw IWK, Summers MJ, Louis R, Trahair L, O'Connor SN, Jones KL, Horowitz M, Chapman MJ, Chapple LAS. Comparison of energy intake in critical illness survivors, general medical patients, and healthy volunteers: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:275-283. [PMID: 38424664 DOI: 10.1002/jpen.2612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group. OBJECTIVE To quantify energy intake and potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers. DESIGN A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test-meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition-impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range [IQR]) or number [percentage]). RESULTS Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS-CoV-2. Energy intake was lower in both patient groups than in health (ICU: 289 [288, 809], GM: 426 [336, 592], health: 815 [654, 1165] kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 [7.0, 11.0], 8.5 [7.0, 9.5], and 8.0 [6.0, 11.0]; and QoL; 60 [40-65], 50 [31-55], and 90 [81-95] out of 100. CONCLUSIONS Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.
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Affiliation(s)
- Elizabeth Viner Smith
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Imre W K Kouw
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Matthew J Summers
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Rhea Louis
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | - Stephanie N O'Connor
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Horowitz
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
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Deane AM, Alhazzani W, Guyatt G, Finfer S, Marshall JC, Myburgh J, Zytaruk N, Hardie M, Saunders L, Knowles S, Lauzier F, Chapman MJ, English S, Muscedere J, Arabi Y, Ostermann M, Venkatesh B, Young P, Thabane L, Billot L, Heels-Ansdell D, Al-Fares AA, Hammond NE, Hall R, Rajbhandari D, Poole A, Johnson D, Iqbal M, Reis G, Xie F, Cook DJ. REVISE: Re- Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol. BMJ Open 2023; 13:e075588. [PMID: 37968012 PMCID: PMC10660838 DOI: 10.1136/bmjopen-2023-075588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER NCT03374800.
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Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Waleed Alhazzani
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lois Saunders
- Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Francois Lauzier
- Departments of Anesthesiology, Medicine & Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, Laval, Quebec, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | | | - Paul Young
- Intensive Care Department, Wellington Hospital, London, UK
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Abdulrahman A Al-Fares
- Departments of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Naomi E Hammond
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - R Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dorrilyn Rajbhandari
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Alexis Poole
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Johnson
- Departments of Critical Care and Anesthesia, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mobeen Iqbal
- Intensive Care Department, Maroof International Hospital, Islamabad, Pakistan
| | - Gilmar Reis
- Cardresearch-Cardiologia Assistencial e de Pesquisa LTDA, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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Summers MJ, Chapple LAS, Bellomo R, Chapman MJ, Ferrie S, Finnis ME, French C, Hurford S, Kakho N, Karahalios A, Maiden MJ, O'Connor SN, Peake SL, Presneill JJ, Ridley EJ, Tran-Duy A, Williams PJ, Young PJ, Zaloumis S, Deane AM. Study protocol for TARGET protein: The effect of augmented administration of enteral protein to critically ill adults on clinical outcomes: A cluster randomised, cross-sectional, double cross-over, clinical trial. CRIT CARE RESUSC 2023; 25:147-154. [PMID: 37876373 PMCID: PMC10581259 DOI: 10.1016/j.ccrj.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background It is unknown whether increasing dietary protein to 1.2-2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this. Objective To describe the study protocol for the TARGET Protein trial. Design setting and participants TARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022. Main outcomes measures The primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination. Conclusion TARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12621001484831).
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Affiliation(s)
- Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Craig French
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nima Kakho
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew J. Maiden
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Stephanie N. O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Jeffrey J. Presneill
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
| | - An Tran-Duy
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Paul J. Young
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - TARGET Protein Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Louis R, Weinel LM, Burrell A, Gardner B, McEwen S, Chapman MJ, O'Connor SN, Chapple LAS. Observed differences in nutrition management at two time points spanning a decade in critically ill trauma patients with and without head injury. Aust Crit Care 2023:S1036-7314(23)00067-X. [PMID: 37391287 DOI: 10.1016/j.aucc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/07/2023] [Accepted: 05/17/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Nutritional needs of trauma patients admitted to the intensive care unit may differ from general critically ill patients, but most current evidence is based on large clinical trials recruiting mixed populations. OBJECTIVE The aim of the study was to investigate nutrition practices at two time points that span a decade in trauma patients with and without head injury. METHODS This observational study recruited adult trauma patients receiving mechanical ventilation and artificial nutrition from a single-centre intensive care unit between February 2005 to December 2006 (cohort 1), and December 2018 to September 2020 (cohort 2). Patients were categorised into head injury and non-head injury subgroups. Data regarding energy and protein prescription and delivery were collected. Data are presented as median [interquartile range]. Wilcoxon rank-sum test assessed the differences between cohorts and subgroups, with a P value ≤ 0.05. The protocol was registered with the Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001816246). RESULTS Cohort 1 included 109 patients, and 112 patients were included in cohort 2 (age: 46 ± 19 vs 50 ± 19 y; 80 vs 79% M). Overall, nutrition practice did not differ between head-injured and non-head-injured subgroups (all P > 0.05). Energy prescription and delivery decreased from time point one to time point two, regardless of subgroup (Prescription: 9824 [8820-10 581] vs 8318 [7694-9071] kJ; Delivery: 6138 [5130-7188] vs 4715 [3059-5996] kJ; all P < 0.05). Protein prescription did not change from time point one to time point two. Although protein delivery remained constant from time point one to time point two in the head injury group, protein delivery reduced in the non-head injury subgroup (70 [56-82] vs 45 [26-64] g/d, P < 0.05). CONCLUSION In this single-centre study, energy prescription and delivery in critically ill trauma patients reduced from time point one to time point two. Protein prescription did not change, but protein delivery reduced from time point one to time point two in non-head injury patients. Reasons for these differing trajectories require exploration. STUDY REGISTRATION Trial registered at www.anzctr.org.au. TRIAL ID ACTRN12618001816246.
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Affiliation(s)
- Rhea Louis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Luke M Weinel
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, VIC, Australia; Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
| | - Bethany Gardner
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Sarah McEwen
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, VIC, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia.
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Chapple LAS, Kouw IWK, Summers MJ, Weinel LM, Gluck S, Raith E, Slobodian P, Soenen S, Deane AM, van Loon LJC, Chapman MJ. Muscle Protein Synthesis Following Protein Administration in Critical Illness. Am J Respir Crit Care Med 2022; 206:740-749. [PMID: 35584344 DOI: 10.1164/rccm.202112-2780oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.
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Affiliation(s)
- Lee-Anne S Chapple
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia;
| | - Imre W K Kouw
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Maastricht University Medical Centre+, 199236, Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, Limburg, Netherlands
| | - Matthew J Summers
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Samuel Gluck
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Eamon Raith
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Peter Slobodian
- Central Adelaide Local Health Network, 375072, Pharmacy, Adelaide, South Australia, Australia
| | - Stijn Soenen
- The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Bond University Faculty of Health Sciences and Medicine, 104559, Gold Coast, Queensland, Australia
| | - Adam M Deane
- The University of Melbourne, 2281, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia
| | - Luc J C van Loon
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Department of Human Biology, Maastricht, Netherlands
| | - Marianne J Chapman
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
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Arunachala Murthy T, Chapple LAS, Lange K, Marathe CS, Horowitz M, Peake SL, Chapman MJ. Gastrointestinal dysfunction during enteral nutrition delivery in intensive care unit (ICU) patients: Risk factors, natural history, and clinical implications. A post-hoc analysis of The Augmented versus Routine approach to Giving Energy Trial (TARGET). Am J Clin Nutr 2022; 116:589-598. [PMID: 35472097 PMCID: PMC9348974 DOI: 10.1093/ajcn/nqac113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/24/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Slow gastric emptying occurs frequently during critical illness and is roughly quantified at bedside by large gastric residual volumes (GRVs). A previously published trial (The Augmented versus Routine approach to Giving Energy Trial; TARGET) reported larger GRVs with energy-dense (1.5 kcal/mL) compared with standard (1.0 kcal/mL) enteral nutrition (EN), warranting further exploration. OBJECTIVE To assess the incidence, risk factors, duration, and timing of large GRVs (≥250 mL) and its relation to clinical outcomes in mechanically ventilated adults. METHODS A post-hoc analysis of TARGET data in patients with ≥1 GRV recorded. Data are n (%) or median [IQR]. RESULTS Of 3876 included patients, 1777 (46%) had ≥1 GRV ≥250 mL, which was more common in males (50 compared with 39%; P < 0.001) and in patients receiving energy-dense compared with standard EN (52 compared with 40%; RR = 1.27 (95% CI: 1.19, 1.36); P < 0.001) in whom it also lasted longer (1 [0-2] compared with 0 [0-1] d; P < 0.001), with no difference in time of onset after EN initiation (day 1 [0-2] compared with 1 [0-2]; P = 0.970). Patients with GRV ≥250 mL were more likely to have the following: vasopressor administration (88 compared with 76%; RR = 1.15 [1.12, 1.19]; P < 0.001), positive blood cultures (16 compared with 8%; RR = 1.92 [1.60, 2.31]; P < 0.001), intravenous antimicrobials (88 compared with 81%; RR = 1.09 [1.06, 1.12]; P < 0.001), and prolonged intensive care unit (ICU) stay (ICU-free days to day 28; 12.9 [0.0-21.0] compared with 20.0 [3.9-24.0]; P < 0.001), hospital stay (hospital-free days to day 28: 0.0 [0.0-12.0] compared with 7.0 [0.0-17.6] d; P < 0.001), ventilatory support (ventilator-free days to day 28: 16.0 [0.0-23.0] compared with 22.0 [8.0-25.0]; P < 0.001), and a higher 90-d mortality (29 compared with 23%; adjusted: RR = 1.17 [1.05, 1.30]; P = 0.003). CONCLUSION Large GRVs were more common in males and those receiving energy-dense formulae, occurred early and were short-lived, and were associated with a number of negative clinical sequelae, including increased mortality, even when adjusted for illness severity. This trial was registered at clinicaltrials.gov as NCT02306746.
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Affiliation(s)
| | - Lee-anne S Chapple
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia
| | - Kylie Lange
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia
| | - Chinmay S Marathe
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,The Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Horowitz
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,The Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Sandra L Peake
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,The Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia,School of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Marianne J Chapman
- Adelaide Medicine School, University of Adelaide, Adelaide, Australia,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia,Centre for Research Excellence in Nutritional Physiology, Adelaide, Australia,School of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
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Murthy TA, Bellomo R, Chapman MJ, Deane AM, Ferrie S, Finnis ME, Hurford S, O’Connor SN, Peake SL, Summers MJ, Williams PJ, Young PJ, Chapple LAS. Protein delivery in mechanically ventilated adults in Australia and New Zealand: current practice. CRIT CARE RESUSC 2021; 23:386-393. [PMID: 38046685 PMCID: PMC10692581 DOI: 10.51893/2021.4.oa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To quantify current protein prescription and delivery in critically ill adults in Australia and New Zealand and compare it with international guidelines. Design: Prospective, multicentre, observational study. Setting: Five intensive care units (ICUs) across Australia and New Zealand. Participants: Mechanically ventilated adults who were anticipated to receive enteral nutrition for ≥ 24 hours. Main outcome measures: Baseline demographic and nutrition data in ICU, including assessment of requirements, prescription and delivery of enteral nutrition, parenteral nutrition and protein supplementation, were collected. The primary outcome was enteral nutrition protein delivery (g/kg ideal body weight [IBW] per day). Data are reported as mean ± standard deviation or n (%). Results: 120 patients were studied (sex, 60% male; mean age, 59 ± 16 years; mean admission APACHE II score, 20 ± 8). Enteral nutrition was delivered on 88%, parenteral nutrition on 6.8%, and protein supplements on 0.3% of 1156 study days. For the 73% (88/120) of patients who had a nutritional assessment, the mean estimated protein requirements were 99 ± 22 g/day (1.46 ± 0.55 g/kg IBW per day). The mean daily protein delivery was 54 ± 23 g (0.85 ± 0.35 g/kg IBW per day) from enteral nutrition and 56 ± 23 g (0.88 ± 0.35 g/kg IBW per day) from all sources (enteral nutrition, parenteral nutrition, protein supplements). Protein delivery was ≥ 1.2 g/kg IBW per day on 29% of the total study days per patient. Conclusions: Protein delivery as a part of current usual care to critically ill adults in Australia and New Zealand remains below that recommended in international guidelines.
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Affiliation(s)
- Tejaswini Arunachala Murthy
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Stephanie N. O’Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Paul J. Young
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
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8
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Whitehead J, Summers MJ, Louis R, Weinel LM, Lange K, Dunn B, Chapman MJ, Chapple LAS. Assessment of physiological barriers to nutrition following critical illness. Clin Nutr 2021; 41:11-20. [PMID: 34861624 DOI: 10.1016/j.clnu.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND & AIMS Nutrition may be important for recovery from critical illness. Gastrointestinal dysfunction is a key barrier to nutrition delivery in the Intensive Care Unit (ICU) and metabolic rate is elevated exacerbating nutritional deficits. Whether these factors persist following ICU discharge is unknown. We assessed whether delayed gastric emptying (GE) and impaired glucose absorption persist post-ICU discharge. METHODS A prospective observational study was conducted in mechanically ventilated adults at 3 time-points: in ICU (V1); on the post-ICU ward (V2); and 3-months after ICU discharge (V3); and compared to age-matched healthy volunteers. On each visit, all participants received a test-meal containing 100 ml of 1 kcal/ml liquid nutrient, labelled with 0.1 g 13C-octanoic acid and 3 g 3-O-Methyl-glucose (3-OMG), and breath and blood samples were collected over 240min to quantify GE (gastric emptying coefficient (GEC)), and glucose absorption (3-OMG concentration; area under the curve (AUC)). Data are mean ± standard error of the mean (SEM) and differences shown with 95% confidence intervals (95%CI). RESULTS Twenty-six critically ill patients completed V1 (M:F 20:6; 62.0 ± 2.9 y; BMI 29.8 ± 1.2 kg/m2; APACHE II 19.7 ± 1.9), 15 completed V2 and eight completed V3; and were compared to 10 healthy volunteers (M:F 6:4; 60.5 ± 7.5 y; BMI 26.0 ± 1.0 kg/m2). GE was significantly slower on V1 compared to health (GEC difference: -0.96 (95%CI -1.61, -0.31); and compared to V2 (-0.73 (-1.16, -0.31) and V3 (-1.03 (-1.47, -0.59). GE at V2 and V3 were not different to that in health (V2: -0.23 (-0.61, 0.14); V3: 0.10 (-0.27, 0.46)). GEC: V1: 2.64 ± 0.19; V2: 3.37 ± 0.12; V3: 3.67 ± 0.10; health: 3.60 ± 0.13. Glucose absorption (3-OMG AUC0-240) was impaired on V1 compared to V2 (-37.9 (-64.2, -11.6)), and faster on V3 than in health (21.8 (0.14, 43.4) but absorption at V2 and V3 did not differ from health. Intestinal glucose absorption: V1: 63.8 ± 10.4; V2: 101.7 ± 7.0; V3: 111.9 ± 9.7; health: 90.7 ± 3.8. CONCLUSION This study suggests that delayed GE and impaired intestinal glucose absorption recovers rapidly post-ICU. This requires further confirmation in a larger population. The REINSTATE trial was prospectively registered at www.anzctr.org.au. TRIAL ID ACTRN12618000370202.
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Affiliation(s)
- James Whitehead
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Rhea Louis
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Luke M Weinel
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Kylie Lange
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Bethany Dunn
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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9
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Gluck S, Andrawos A, Summers MJ, Lange J, Chapman MJ, Finnis ME, Deane AM. The use of smartphone-derived location data to evaluate participation following critical illness: A pilot observational cohort study. Aust Crit Care 2021; 35:225-232. [PMID: 34373172 DOI: 10.1016/j.aucc.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/03/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Disability is common following critical illness, impacting the quality of life of survivors, and is difficult to measure. 'Participation' can be quantified as involvement in life outside of their home requiring movement from their home to other locations. Participation restriction is a key element of disability, and following critical illness, participation may be diminished. It may be possible to quantify this change using pre-existing smartphone data. OBJECTIVES The feasibility of extracting location data from smartphones of survivors of intensive care unit (ICU) admission and assessing participation, using location-based outcomes, during recovery from critical illness was evaluated. METHODS Fifty consecutively admitted, consenting adult survivors of non-elective admission to ICU of greater than 48-h duration were recruited to a prospective observational cohort study where they were followed up at 3 and 6 months following discharge. The feasibility of extracting location data from survivors' smartphones and creating location-derived outcomes assessing participation was investigated over three 28-d study periods: pre-ICU admission and at 3 and 6 months following discharge. The following were calculated: time spent at home; the number of destinations visited; linear distance travelled; and two 'activity spaces', a minimum convex polygon and standard deviation ellipse. RESULTS Results are median [interquartile range] or n (%). The number of successful extractions was 9/50 (18%), 12/39 (31%), and 13/33 (39%); the percentage of time spent at home was 61 [56-68]%, 77 [66-87]%, and 67 [58-77]% (P = 0.16); the number of destinations visited was 34 [18-64], 38 [22-63], and 65 [46-88] (P = 0.02); linear distance travelled was 367 [56-788], 251 [114-323], and 747 [326-933] km over 28 d (P = 0.02), pre-ICU admission and at 3 and 6 months following ICU discharge, respectively. Activity spaces were successfully created. CONCLUSION Limited smartphone ownership, missing data, and time-consuming data extraction limit current implementation of mass extraction of location data from patients' smartphones to aid prognostication or measure outcomes. The number of journeys taken and the linear distance travelled increased between 3 and 6 months, suggesting participation may improve over time.
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Affiliation(s)
- Samuel Gluck
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Alice Andrawos
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Matthew J Summers
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia.
| | - Jarrod Lange
- Hugo Centre for Population and Housing, University of Adelaide, Napier Building, North Terrace, Adelaide, SA 5000, Australia.
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Mark E Finnis
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Adam M Deane
- Intensive Care Unit, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3010, Australia; The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia, VIC 3050.
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10
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Wong HZ, Brusseleers M, Hall KA, Maiden MJ, Chapple LAS, Chapman MJ, Hodgson CL, Gluck S. Mixed-mode versus paper surveys for patient-reported outcomes after critical illness: A randomised controlled trial. Aust Crit Care 2021; 35:286-293. [PMID: 34176735 DOI: 10.1016/j.aucc.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The aim of the study was to determine the response rate to a mixed-mode survey using email compared with that to a paper survey in survivors of critical illness. DESIGN This is a prospective randomised controlled trial. SETTING The study was conducted at a single-centre quaternary intensive care unit (ICU) in Adelaide, Australia. PARTICIPANTS Study participants were patients admitted to the ICU for ≥48 h and discharged from the hospital. INTERVENTIONS The participants were randomised to receive a survey by paper (via mail) or via online (via email, or if a non-email user, via a letter with a website address). Patients who did not respond to the initial survey received a reminder paper survey after 14 days. The survey included quality of life (EuroQol-5D-5L), anxiety and depression (Hospital Anxiety and Depression Scale), and post-traumatic symptom (Impact of Event Scale-Revised) assessment. MAIN OUTCOME MEASURES Survey response rate, extent of survey completion, clinical outcomes at different time points after discharge, and survey cost analysis were the main outcome measures. Outcomes were stratified based on follow-up time after ICU discharge (3, 6, and 12 months). RESULTS A total of 239 patients were randomised. The response rate was similar between the groups (mixed-mode: 78% [92/118 patients] vs. paper: 80% [97/121 patients], p = 0.751) and did not differ between time points of follow-up. Incomplete surveys were more prevalent in the paper group (10% vs 18%). The median EuroQol-5D-5L index value was 0.83 [0.71-0.92]. Depressive symptoms were reported by 25% of patients (46/187), anxiety symptoms were reported by 27% (50/187), and probable post-traumatic stress disorder was reported by 14% (25/184). Patient outcomes did not differ between the groups or time points of follow-up. The cost per reply was AU$ 16.60 (mixed-mode) vs AU$ 19.78 (paper). CONCLUSION The response rate of a mixed-mode survey is similar to that of a paper survey and may provide modest cost savings.
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Affiliation(s)
- Hao Z Wong
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | | | - Kelly A Hall
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia.
| | - Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Intensive Care Unit, Barwon Health, Geelong, Victoria, Australia; School of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; School of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; School of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Carol L Hodgson
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Samuel Gluck
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; School of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
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Chapple LAS, Summers MJ, Weinel LM, Abdelhamid YA, Kar P, Hatzinikolas S, Calnan D, Bills M, Lange K, Poole A, O'Connor SN, Horowitz M, Jones KL, Deane AM, Chapman MJ. Effects of Standard vs Energy-Dense Formulae on Gastric Retention, Energy Delivery, and Glycemia in Critically Ill Patients. JPEN J Parenter Enteral Nutr 2021; 45:710-719. [PMID: 33543797 DOI: 10.1002/jpen.2065] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/20/2020] [Accepted: 12/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Energy-dense formulae are often provided to critically ill patients with enteral feed intolerance with the aim of increasing energy delivery, yet the effect on gastric emptying is unknown. The rate of gastric emptying of a standard compared with an energy-dense formula was quantified in critically ill patients. METHODS Mechanically ventilated adults were randomized to receive radiolabeled intragastric infusions of 200 mL standard (1 kcal/mL) or 100 mL energy-dense (2 kcal/mL) enteral formulae on consecutive days in this noninferiority, blinded, crossover trial. The primary outcome was scintigraphic measurement of gastric retention (percentage at 120 minutes). Other measures included area under the curve (AUC) for gastric retention and intestinal energy delivery (calculated from gastric retention of formulae over time), blood glucose (peak and AUC), and intestinal glucose absorption (using 3-O-methyl-D-gluco-pyranose [3-OMG] concentrations). Comparisons were undertaken using paired mixed-effects models. Data presented are mean ± SE. RESULTS Eighteen patients were studied (male/female, 14:4; age, 55.2 ± 5.3 years). Gastric retention at 120 minutes was greater with the energy-dense formula (standard, 17.0 ± 5.9 vs energy-dense, 32.5 ± 7.1; difference, 12.7% [90% confidence interval, 0.8%-30.1%]). Energy delivery (AUC120 , 13,038 ± 1119 vs 9763 ± 1346 kcal/120 minutes; P = 0.057), glucose control (peak glucose, 10.1 ± 0.3 vs 9.7 ± 0.3 mmol/L, P = 0.362; and glucose AUC120 8.7 ± 0.3 vs 8.5 ± 0.3 mmol/L.120 minutes, P = 0.661), and absorption (3-OMG AUC120 , 38.5 ± 4.0 vs 35.7 ± 4.0 mmol/L.120 minutes; P = .508) were not improved with the energy-dense formula. CONCLUSION In critical illness, administration of an energy-dense formula does not reduce gastric retention, increase energy delivery to the small intestine, or improve glucose absorption or glucose control; instead, there is a signal for delayed gastric emptying.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Medicine and Radiology, The University of Melbourne, Melbourne Medical School,Royal Melbourne Hospital, Parkville, Australia
| | - Palash Kar
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Seva Hatzinikolas
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Deborah Calnan
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Madison Bills
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kylie Lange
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alexis Poole
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Adam M Deane
- Department of Medicine and Radiology, The University of Melbourne, Melbourne Medical School,Royal Melbourne Hospital, Parkville, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
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Deane AM, Chapman MJ. Technology to inform the delivery of enteral nutrition in the intensive care unit. JPEN J Parenter Enteral Nutr 2021; 46:754-756. [PMID: 33928654 DOI: 10.1002/jpen.2137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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Murthy TA, Grivell J, Hatzinikolas S, Chapple LAS, Chapman MJ, Stevens JE, Malbert CH, Rayner CK, Horowitz M, Jones KL, Marathe CS. Acceleration of Gastric Emptying by Insulin-Induced Hypoglycemia is Dependent on the Degree of Hypoglycemia. J Clin Endocrinol Metab 2021; 106:364-371. [PMID: 33230553 DOI: 10.1210/clinem/dgaa854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Hypoglycemia is a major barrier to optimal glycemic control in insulin-treated diabetes. Recent guidelines from the American Diabetes Association have subcategorized "non-severe" hypoglycemia into level 1 (<3.9 mmol/L) and 2 (<3 mmol/L) hypoglycemia. Gastric emptying of carbohydrate is a major determinant of postprandial glycemia but its role in hypoglycemia counter-regulation remains underappreciated. "Marked" hypoglycemia (~2.6 mmol/L) accelerates gastric emptying and increases carbohydrate absorption in health and type 1 diabetes, but the impact of "mild" hypoglycemia (3.0-3.9 mmol/L) is unknown. OBJECTIVE To determine the effects of 2 levels of hypoglycemia, 2.6 mmol/L ("marked") and 3.6 mmol/L ("mild"), on gastric emptying in health. DESIGN, SETTING, AND SUBJECTS Fourteen healthy male participants (mean age: 32.9 ± 8.3 years; body mass index: 24.5 ± 3.4 kg/m2) from the general community underwent measurement of gastric emptying of a radiolabeled solid meal (100 g beef) by scintigraphy over 120 minutes on 3 separate occasions, while blood glucose was maintained at either ~2.6 mmol/L, ~3.6 mmol/L, or ~6 mmol/L in random order from 15 minutes before until 60 minutes after meal ingestion using glucose-insulin clamp. Blood glucose was then maintained at 6 mmol/L from 60 to 120 minutes on all days. RESULTS Gastric emptying was accelerated during both mild (P = 0.011) and marked (P = 0.001) hypoglycemia when compared to euglycemia, and was more rapid during marked compared with mild hypoglycemia (P = 0.008). Hypoglycemia-induced gastric emptying acceleration during mild (r = 0.57, P = 0.030) and marked (r = 0.76, P = 0.0014) hypoglycemia was related to gastric emptying during euglycemia. CONCLUSION In health, acceleration of gastric emptying by insulin-induced hypoglycemia is dependent on the degree of hypoglycemia and baseline rate of emptying.
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Affiliation(s)
- Tejaswini Arunachala Murthy
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | - Seva Hatzinikolas
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Christopher K Rayner
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Horowitz
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Karen L Jones
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Chinmay S Marathe
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
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14
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Chapple LAS, Summers MJ, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Finnis ME, Hurford S, Lange K, Little L, O'Connor SN, Peake SL, Ridley EJ, Young PJ, Williams PJ, Deane AM. Use of a High-Protein Enteral Nutrition Formula to Increase Protein Delivery to Critically Ill Patients: A Randomized, Blinded, Parallel-Group, Feasibility Trial. JPEN J Parenter Enteral Nutr 2020; 45:699-709. [PMID: 33296079 DOI: 10.1002/jpen.2059] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. METHODS We conducted a prospective, randomized, blinded, parallel-group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). RESULTS The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high-protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38-0.69] g/kg/d protein), with no difference in energy delivery (difference, -26 [95% CI, -190 to 137] kcal/kg/d). There were no between-group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90-day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, -1.3% [95% CI, -17.7% to 15.0%]). CONCLUSION Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline-recommended levels with doses similar to usual care during critical illness.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Matthew J Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia.,The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, Frankston Hospital, Frankston, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Patricia J Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
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- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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15
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Chapple LAS, Ridley EJ, Chapman MJ. Trial Design in Critical Care Nutrition: The Past, Present and Future. Nutrients 2020; 12:nu12123694. [PMID: 33265999 PMCID: PMC7760682 DOI: 10.3390/nu12123694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/19/2020] [Accepted: 11/26/2020] [Indexed: 12/26/2022] Open
Abstract
The specialty of nutrition in critical care is relatively modern, and accordingly, trial design has progressed over recent decades. In the past, small observational and physiological studies evolved to become small single-centre comparative trials, but these had significant limitations by today’s standards. Power calculations were often not undertaken, outcomes were not specified a priori, and blinding and randomisation were not always rigorous. These trials have been superseded by larger, more carefully designed and conducted multi-centre trials. Progress in trial conduct has been facilitated by a greater understanding of statistical concepts and methodological design. In addition, larger numbers of potential study participants and increased access to funding support trials able to detect smaller differences in outcomes. This narrative review outlines why critical care nutrition research is unique and includes a historical critique of trial design to provide readers with an understanding of how and why things have changed. This review focuses on study methodology, population group, intervention, and outcomes, with a discussion as to how these factors have evolved, and concludes with an insight into what we believe trial design may look like in the future. This will provide perspective on the translation of the critical care nutrition literature into clinical practice.
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Affiliation(s)
- Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA 5005, Australia
- Correspondence: ; Tel.: +61-428-269-179
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC 3004, Australia;
- Nutrition Department, Alfred Health, Melbourne, VIC 3004, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia;
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA 5005, Australia
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16
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Deane AM, Bellomo R, Chapman MJ, Lange K, Peake SL, Young P, Iwashyna TJ. Reply to Peçanha Antonio et al.: Too Many Calories for All? Am J Respir Crit Care Med 2020; 202:1060. [PMID: 32516545 PMCID: PMC7528800 DOI: 10.1164/rccm.202005-1810le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Adam M Deane
- The University of Melbourne, Parkville, Victoria, Australia
| | | | | | - Kylie Lange
- University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L Peake
- University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand and
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17
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Yk Yeo N, Aj Reddi B, Schultz CG, O'Connor SN, Chapman MJ, S Chapple LA. Early anthropometry, strength, and function in survivors of critical illness. Aust Crit Care 2020; 34:33-37. [PMID: 32727702 DOI: 10.1016/j.aucc.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/18/2020] [Accepted: 05/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Critically ill patients experience acute muscle wasting and long-term functional impairments, yet this has been inadequately categorised early in recovery. OBJECTIVE This observational study aimed to evaluate anthropometry, strength, and muscle function after intensive care unit discharge. METHODS Adult patients able to complete study measures after prolonged intensive care unit stay (≥5 d) were eligible. Demographic and clinical data were collected, and bodyweight, height, triceps skinfold, trunk length, handgrip strength, 6-minute walk test, whole-body dual-energy x-ray absorptiometry, and mid-thigh, knee, and above-ankle circumferences were measured. Body cell mass was calculated from these data. Data are presented as mean (standard deviation) or median [interquartile range]. RESULTS Fourteen patients (50% male; 57 [10.5] years) were assessed 11.1 (6.9) d after intensive care unit discharge. Patients lost 4.76 (6.66) kg in the intensive care unit. Triceps skinfold thickness (17.00 [8.65] mm) and handgrip strength (12.60 [8.57] kg) were lower than normative data. No patient could commence the 6-minute walk test. Dual-energy x-ray absorptiometry-derived muscle mass correlated with handgrip strength (R = 0.57; 95% confidence interval = 0.06-0.85; p = 0.03), but body cell mass did not. CONCLUSIONS Anthropometry and strength in intensive care unit survivors are below normal. Muscle mass derived from dual-energy x-ray absorptiometry correlates with handgrip strength but body cell mass does not.
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Affiliation(s)
- Nikki Yk Yeo
- Intensive Care Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia
| | - Benjamin Aj Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia
| | - Christopher G Schultz
- Department of Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia
| | - Marianne J Chapman
- Director of Intensive Care Clinical Research Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia
| | - Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, 5000, Australia.
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18
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Ojha M, Finnis ME, Heckelmann M, Raith EP, Moodie S, Chapman MJ, Reddi B, Maiden MJ. Outcomes following grade V subarachnoid haemorrhage: A single-centre retrospective study. Anaesth Intensive Care 2020; 48:289-296. [PMID: 32659113 DOI: 10.1177/0310057x20927033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SummaryGrade V subarachnoid haemorrhage is associated with high mortality and morbidity, yet there are few contemporary reports on the treatment provided and outcomes of these patients. In this single-centre retrospective cohort study, we primarily sought to determine the 12-month mortality of patients admitted to the Royal Adelaide Hospital intensive care unit between 2006 and 2016 with grade V subarachnoid haemorrhage. Secondary objectives were to describe treatments provided, patient destination following hospital discharge, organ donation and hospital financial costs. Over the 11-year study period, there were 139 patients admitted with grade V subarachnoid haemorrhage. The annual number of admissions did not change over time. The median age was 56 (interquartile range 48-70) years, 88 (63%) were female and 77 (55%) had a procedure to isolate an aneurysm. There were 77 (55%) patients who died in the intensive care unit, 87 (63%) died in hospital and 89 (64%) had died at 12 months. Of the 52 patients who survived to hospital discharge, 33 (63%) were transferred to a rehabilitation facility, 17 (33%) to another acute care hospital and two (4%) were discharged. Of the 87 patients who died in hospital, 45 (52%) donated organs. The total hospital cost of managing this cohort was A$8.3 million, with a median cost of A$41,824 (interquartile range A$9,933-A$97,332) per patient. Grade V subarachnoid haemorrhage has a high mortality rate, with one-third of patients alive after one year.
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Affiliation(s)
- Minny Ojha
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael Heckelmann
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Eamon P Raith
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stewart Moodie
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Donate Life SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care Unit, Barwon Health, Geelong, Australia
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19
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Reid AL, Chapman MJ, Peake SL, Bellomo R, Davies A, Deane AM, Horowitz M, Hurford S, Lange K, Little L, Mackle D, O'Connor SN, Ridley EJ, Williams PJ, Young PJ. Energy-dense vs routine enteral nutrition in New Zealand Europeans, Māori, and Pacific Peoples who are critically ill. N Z Med J 2020; 133:72-82. [PMID: 32525863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
AIMS To evaluate the effect of energy-dense vs routine enteral nutrition on day-90 mortality by ethnic group in critically ill adults. METHODS Pre-planned subgroup analysis of the 1,257 New Zealanders in a 4,000-participant randomised trial comparing energy-dense enteral nutrition (1.5kcal/mL) with routine enteral nutrition (1kcal/mL) in mechanically ventilated intensive care unit (ICU) patients. The primary purpose of this analysis was to evaluate responses to study treatment by ethnic group (European, Māori, and Pacific Peoples) using ethnicity data recorded in the clinical records. The secondary purpose was to compare the characteristics and outcomes of patients by ethnic group. The primary outcome was day-90 mortality. RESULTS Among 1,138 patients included in the primary outcome analysis, 165 of 569 (29.0%) assigned to energy-dense nutrition and 156 of 569 patients (27.4%) assigned to routine nutrition died by day 90 (odds ratio; 1.06; 95% CI, 0.92-1.22). There was no statistically significant interaction between treatment allocation and ethnicity with respect to day-90 mortality. Day-90 mortality rates did not vary statistically significantly by ethnic group. CONCLUSIONS Among mechanically ventilated adults in New Zealand ICUs, the effect on day-90 mortality of energy-dense vs routine enteral nutrition did not vary by ethnicity.
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Affiliation(s)
- Alice L Reid
- Research Fellow, Medical Research Institute of New Zealand, Wellington
| | - Marianne J Chapman
- Research Director, Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Professor, Faculty of Health and Medical Sciences, The University of Adelaide, SA, Australia; Adjunct Associate Professor, School of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
| | - Sandra L Peake
- Director, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville South, SA, Australia; Professor, Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia; Adjunct Associate Professor, School of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
| | - Rinaldo Bellomo
- Intensive Care Specialist, Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia
| | - Andrew Davies
- Intensive Care Specialist, Intensive Care Unit, Frankston, VIC, Australia
| | - Adam M Deane
- Principal Research Fellow, The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Michael Horowitz
- Professor of Medicine & Head Endocrine Unit, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Sally Hurford
- ICU Trials Project Manager, Medical Research Institute of New Zealand, Wellington
| | - Kylie Lange
- Biostatistician, Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, SA, Australia
| | - Lorraine Little
- Project Manager, School of Epidemiology and Preventive Medicine, Monash University, VIC, Australia
| | - Diane Mackle
- ICU Programme Manager, Medical Research Institute of New Zealand, Wellington
| | - Stephanie N O'Connor
- ICU Clinical Research Manager, Royal Adelaide Hospital, Adelaide, SA, Australia; Affiliate Senior Lecturer, Acute Care Medicine, The University of Adelaide, SA, Australia
| | - Emma J Ridley
- Senior Research Fellow, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Patricia J Williams
- Research Coordinator, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville South, SA, Australia; Affiliate Lecturer, Acute Care Medicine, The University of Adelaide, SA, Australia; Adjunct Research Fellow, Department of Epidemiology and Preventative Medicine, Monash University, VIC, Australia
| | - Paul J Young
- Deputy Director, Medical Research Institute of New Zealand, Wellington; Intensive Care Specialist, Wellington Hospital, Wellington
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20
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Deane AM, Little L, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Horowitz M, Hurford S, Lange K, Litton E, Mackle D, O'Connor S, Parker J, Peake SL, Presneill JJ, Ridley EJ, Singh V, van Haren F, Williams P, Young P, Iwashyna TJ. Outcomes Six Months after Delivering 100% or 70% of Enteral Calorie Requirements during Critical Illness (TARGET). A Randomized Controlled Trial. Am J Respir Crit Care Med 2020; 201:814-822. [PMID: 31904995 DOI: 10.1164/rccm.201909-1810oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown.Objectives: Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later.Methods: We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition.Measurements and Main Results: Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work (n = 818). There was no observed difference in disability (n = 1,208) or participation in key life activities (n = 705).Conclusions: The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.
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Affiliation(s)
- Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | | | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | | | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Jeffrey J Presneill
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vanessa Singh
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Frank van Haren
- Medical School, Australian National University, Canberra, Australia; and
| | | | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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21
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Abstract
PURPOSE OF REVIEW The care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery. RECENT FINDINGS Overall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areas: patient factors; clinician factors; and system factors. SUMMARY A nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.
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Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University
- Nutrition Department, Alfred Health, Melbourne
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide
- Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide
- Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia
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22
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Chapman MJ, Jones KL, Almansa C, Barnes CN, Nguyen D, Deane AM. Blinded, Double-Dummy, Parallel-Group, Phase 2a Randomized Clinical Trial to Evaluate the Efficacy and Safety of a Highly Selective 5-Hydroxytryptamine Type 4 Receptor Agonist in Critically Ill Patients With Enteral Feeding Intolerance. JPEN J Parenter Enteral Nutr 2020; 45:115-124. [PMID: 31990087 PMCID: PMC7891369 DOI: 10.1002/jpen.1732] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/23/2019] [Accepted: 10/05/2019] [Indexed: 12/22/2022]
Abstract
Background Delayed gastric emptying is the leading cause of enteral feeding intolerance (EFI) in critical illness. This phase 2a study compared TAK‐954, a selective agonist of 5‐hydroxytryptamine type 4 receptors, with metoclopramide in critically ill patients with EFI (NCT01953081). Methods A blinded, double‐dummy trial was conducted in mechanically ventilated patients with EFI (>200 mL gastric residual volume within 24 hours before randomization). Patients were randomized to receive either 0.5 mg intravenous TAK‐954 over 1 hour then 0.9% saline injection 4 times/d (sham metoclopramide) or the active comparator 10 mg intravenous metoclopramide 4 times/d and a 1‐hour 0.9% saline infusion. After initial dosing, participants received a radiolabeled meal of liquid nutrient (Ensure; 106 kcal), and gastric emptying was measured (scintigraphy). Adverse events (AEs) were recorded from the time of consent through to day 5; serious AEs were collected to day 30. Results Thirteen patients (TAK‐954, n = 7; metoclopramide, n = 6) participated. Five patients in the TAK‐954 group and 4 in the metoclopramide group experienced AEs (2 and 3, respectively, were serious). All AEs except 1 (diarrhea in the metoclopramide group) were considered unrelated to study drug. Following treatment, a greater proportion of patients receiving TAK‐954 had normal gastric retention (<13% retention at 180 minutes) than those receiving metoclopramide (6/7 vs 3/6 patients, respectively). Conclusion A single dose of 0.5 mg intravenous TAK‐954 appears to have at least similar efficacy in accelerating gastric emptying to multiple doses of 10 mg metoclopramide and was not associated with increased AEs.
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Affiliation(s)
- Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Cristina Almansa
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Deanna Nguyen
- Theravance Biopharma US, Inc., South San Francisco, California, USA
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Chapman MJ, Surikow S, Stadler D, Rose J, Henthorn R, Aldridge E, Zeitz CJ. P909 Diagnostic evaluation of rheumatic heart disease in aborigonal population. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Among Indigenous Australians, rates of Acute Rheumatic Fever (ARF) continue to be among the highest in the world. Diagnosis remains a clinical decision based on identification of major and minor manifestations of the illness. Treatment involves lengthy prophylaxis and should continue for a minimum of 10 years.
ARF can cause permanent damage to the heart known as rheumatic heart disease (RHD).
We therefore utilised echocardiography as a diagnostic tool incorporating Tissue Quantification Backscatter expressed in decibels (dB) and global LV work efficiency estimated from left ventricle (LV) pressure-strain loops to identify rheumatic changes of the Mitral Valve and help improve early diagnosis of RHD.
Method
Data from patients with suspected RHD (n = 14), and age matched controls (n = 10) underwent Mitral Valve Backscatter Analysis (MVBS). MVBS was expressed as a ratio % (MVBS ratio %) by dividing the average MVBS and the average blood pool value expressed in decibels (dB). Furthermore LV function was utilised via 2D longitudinal strain and indices of myocardial work were derived.
Result
MVBS ratio % was significantly higher in the control group as compared to the RHD group (p = 0.001) (fig1). Of the RHD group echocardiography parameters showed there were no significant mitral valve stenosis or regurgitation. Correlates of LV function included: Global work Index (GWI), Global longitudinal Strain (GLS) and Global work efficiency (GWE). Of the above correlates the control group showed Backscatter vs GLS (r= -0.89, p = 0.001), the RHD group: Backscatter vs GLS (r = 0.52. p = 0.12). Within the RHD group the ratio vs GWE (r= 0.57, p = 0.09) these results showed a trend to significance.
Conclusions
Currently diagnosis of RHD remains a clinical decision based on the identification of major and minor manifestations. In addition treatment involves prophylaxis injections for a minimum of ten years. Of this group there were no significant echocardiography changes, rather clinical manifestation to derive RHD.
This study shows that calibrated MVBS ratio % and determinants of myocardial work may be a promising quantitative tool to detect early manifestation of RHD potentially aiding an early treatment plan and thus reducing the clinical burden of monthly penicillin injections for a ten year period.
Abstract P909 Figure. RHD and Myocardial correlates
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Affiliation(s)
- M J Chapman
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - S Surikow
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - D Stadler
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - J Rose
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - R Henthorn
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - E Aldridge
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - C J Zeitz
- The Lyell McEwin Hospital, Elizabeth Vale, Australia
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24
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Chapple LAS, Weinel L, Ridley EJ, Jones D, Chapman MJ, Peake SL. Clinical Sequelae From Overfeeding in Enterally Fed Critically Ill Adults: Where Is the Evidence? JPEN J Parenter Enteral Nutr 2019; 44:980-991. [PMID: 31736105 DOI: 10.1002/jpen.1740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 10/11/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022]
Abstract
Enteral energy delivery above requirements (overfeeding) is believed to cause adverse effects during critical illness, but the literature supporting this is limited. We aimed to quantify the reported frequency and clinical sequelae of energy overfeeding with enterally delivered nutrition in critically ill adult patients. A systematic search of MEDLINE, EMBASE, and CINAHL from conception to November 28, 2018, identified clinical studies of nutrition interventions in enterally fed critically ill adults that reported overfeeding in 1 or more study arms. Overfeeding was defined as energy delivery > 2000 kcal/d, > 25 kcal/kg/d, or ≥ 110% of energy prescription. Data were extracted on methodology, demographics, prescribed and delivered nutrition, clinical variables, and predefined outcomes. Cochrane "Risk of Bias" tool was used to assess the quality of randomized controlled trials (RCTs). Eighteen studies were included, of which 10 were randomized (n = 4386 patients) and 8 were nonrandomized (n = 223). Only 4 studies reported a separation in energy delivery between treatment groups whereby 1 arm met the definition of overfeeding, which reported no between-group differences in mortality, infectious complications, or ventilatory support. Overfeeding was associated with increased insulin administration (median 3 [interquartile range: 0-41.8] vs 0 [0-30.6] units/d) and upper-gastrointestinal intolerance in 1 large RCT and with duration of antimicrobial therapy in a small RCT. There are limited high-quality data to determine the impact of energy overfeeding of critically ill patients by the enteral route; however, based on available evidence, overfeeding does not appear to affect mortality or other important clinical outcomes.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Luke Weinel
- Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Emma J Ridley
- Australaian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University Melbourne, Melbourne, Australia.,Nutrition Department, Alfred Health, Melbourne, Australia
| | - Daryl Jones
- Intensive Care Unit, Austin Health, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University Melbourne, Melbourne, Australia
| | - Marianne J Chapman
- Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Sandra L Peake
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
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25
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Young PJ, Bellomo R, Chapman MJ, Deane AM, Peake SL. What should we target after TARGET? CRIT CARE RESUSC 2018; 20:252-253. [PMID: 30482131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Paul J Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand.
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Melbourne, Vic, Australia
| | | | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Sandra L Peake
- Department of Intensive Care Medicine, Queen Elizabeth Hospital, Adelaide, SA, Australia
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26
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Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract 2018; 34:23-36. [PMID: 30294835 DOI: 10.1002/ncp.10199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among individuals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Center of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Stephen A McClave
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Anton Emmanuel
- Department of Neuro-Gastroenterology, University College London, London, UK
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27
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Sampson BG, Wilson SR, Finnis ME, Hodak AM, Jones PN, O'Connor SL, Chapman MJ. A Quality Control Study of the Adherence to Recommended Physiological Targets for the Management of Brain-Dead Organ Donors in South Australian Intensive Care Units. Prog Transplant 2018; 28:386-389. [PMID: 30222049 DOI: 10.1177/1526924818800053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Australian and New Zealand Intensive Care Society and the Australasian Transplant Coordinators Association provide recommendations on the physiological management of brain-dead donors. PROBLEM STATEMENT How often physiological targets are prescribed for brain-dead donors in Australian intensive care units (ICUs), and how well these compare to recommended targets is unknown. It is also unknown how often recommended targets are achieved, irrespective of prescribed targets. METHODS We performed a retrospective, observational quality control study in 81 adult (>18 years) brain-dead donors to describe how often physiological targets were prescribed, comparing these to current guidelines. We determined the proportion of observations within the recommended target range, irrespective of any prescribed target. We aimed to identify poor adherence to recommended targets to guide future quality improvement initiatives. OUTCOMES Seventy-four (91%) donors had at least 1 prescribed physiological target written on the ICU chart, with a median of 2 (range 2-5), and a maximum of 13 targets. Prescribed targets appeared to adhere well with recommended targets. Most recommended physiological targets were met irrespective of any prescribed target. However, one-quarter of serum sodium observations and one-third of blood glucose levels were above the recommended target. IMPLICATIONS FOR PRACTICE Quality improvement initiatives are required to improve the prescription of physiological targets in brain-dead donors in South Australia. Serum sodium and serum glucose targets were not met. However, this most likely reflects the need for current guidelines to be updated in line with current evidence.
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Affiliation(s)
- Brett G Sampson
- 1 Intensive and critical care Unit, Flinders Medical Centre, Bedford Park, Australia.,2 DonateLife SA, Adelaide, South Australia, Australia.,3 Department of Critical Care Medicine, Flinders University, Bedford Park, Australia
| | - Steven R Wilson
- 4 Department of Anaesthesia, Flinders Medical Centre, Bedford Park, Australia
| | - Mark E Finnis
- 5 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | | | - Stephanie L O'Connor
- 5 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Marianne J Chapman
- 5 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,6 School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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28
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Chapple LAS, Weinel LM, Abdelhamid YA, Summers MJ, Nguyen T, Kar P, Lange K, Chapman MJ, Deane AM. Observed appetite and nutrient intake three months after ICU discharge. Clin Nutr 2018; 38:1215-1220. [PMID: 29778511 DOI: 10.1016/j.clnu.2018.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 04/12/2018] [Accepted: 05/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Oral intake is diminished immediately after ICU discharge, yet factors affecting nutritional intake after hospital discharge have not been evaluated. The aim of this study was to evaluate dietary intake and factors which may influence intake - appetite and gastric emptying - 3-months after ICU discharge. METHODS Inception cohort study with ICU survivors compared to healthy subjects. Following an overnight fast, all participants consumed a standardized carbohydrate drink, containing 13C-octanoic acid, to measure gastric emptying. Dietary intake was assessed by recall of the preceding day and a standard weighed buffet meal 4-h post-drink. Appetite was assessed pre-drink (fasting) and pre- and post-buffet using visual analogue scales. RESULTS Fifty-one ICU survivors (82% male; 70 ± 9 y; BMI 28 ± 6 kg/m2) and 25 healthy subjects (60% male; 67 ± 12 y; BMI 27 ± 4 kg/m2) were evaluated. From the 24-h recall ICU survivors consumed less calories (ICU 1876 (708) vs. healthy subjects 2291 (834) kcal; p = 0.025) with no difference in macronutrient intake, however reported a lower preference for fat (p < 0.001). Calorie and macronutrient intake from the weighed buffet was similar between groups: calories (ICU: 658 (301) vs. healthy subjects: 736 (325) kcal; p = 0.149); protein (ICU: 37 (19) vs. healthy subjects: 40 (17) g; p = 0.275); fat (ICU: 23 (12) vs healthy subjects: 26 (13) g; p = 0.261); and carbohydrates (ICU: 69 (35) vs. healthy subjects: 79 (42) g; p = 0.141). ICU survivors reported feeling less full regardless of time-point (p = 0.041). There was no difference in the rate of gastric emptying between the two groups (p = 0.216). CONCLUSIONS ICU survivors reported less preference for fat and less calorie consumption than healthy subjects. However, intake of calories and macronutrients at a weighed meal was similar in the two groups, as was the rate of gastric emptying. ICU survivors reported being less full after the test meal, suggesting factors other than appetite may influence intake.
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Affiliation(s)
- Lee-Anne S Chapple
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.
| | - Luke M Weinel
- Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew J Summers
- Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Thu Nguyen
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia
| | - Palash Kar
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Kylie Lange
- National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Australia; National Health and Medical Research Council of Australia Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
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29
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Deane AM, Peake SL, Chapman MJ. The disconnect between nutrition guidelines and evidence: how much protein should I prescribe to this critically ill patient? CRIT CARE RESUSC 2018; 20:3-5. [PMID: 29458315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Adam M Deane
- Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Sandra L Peake
- Department of Intensive Care Medicine, Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Marianne J Chapman
- Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
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30
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Deane AM, Lamontagne F, Dukes GE, Neil D, Vasist L, Barton ME, Hacquoil K, Ou X, Richards D, Stelfox HT, Mehta S, Day AG, Chapman MJ, Heyland DK. Nutrition Adequacy Therapeutic Enhancement in the Critically Ill: A Randomized Double-Blind, Placebo-Controlled Trial of the Motilin Receptor Agonist Camicinal (GSK962040): The NUTRIATE Study. JPEN J Parenter Enteral Nutr 2017; 42:949-959. [DOI: 10.1002/jpen.1038] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/02/2017] [Accepted: 10/16/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Adam M. Deane
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide Australia
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide Australia
- Intensive Care Unit; Royal Melbourne Hospital; Melbourne Australia
| | - Francois Lamontagne
- Department of Medicine; Université de Sherbrooke; Sherbrooke Canada
- Centre Hospitalier Universitaire de Sherbrooke; Sherbrooke Canada
| | - George E. Dukes
- GlaxoSmithKline R&D; Research Triangle Park; North Caroliana USA
| | - David Neil
- GlaxoSmithKline R&D; Research Triangle Park; North Caroliana USA
| | - Lakshmi Vasist
- GlaxoSmithKline R&D; Research Triangle Park; North Caroliana USA
| | - Matthew E. Barton
- GlaxoSmithKline R&D; Research Triangle Park; North Caroliana USA
- Mallinckrodt Pharmaceuticals, Inc.; Hampton New Jersey USA
| | | | | | | | - Henry T. Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health; University of Calgary; Calgary Alberta Canada
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental, Division of Critical Care Medicine; Sinai Health System and University of Toronto; Toronto, Canada
| | - Andrew G. Day
- Clinical Evaluation Research Unit, Kingston General Hospital; Kingston Canada
| | - Marianne J. Chapman
- Department of Critical Care Services; Royal Adelaide Hospital; Adelaide Australia
- Discipline of Acute Care Medicine; University of Adelaide; Adelaide Australia
| | - Daren K. Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital; Kingston Canada
- Department of Critical Care Medicine; Queen's University; Kingston Ontario Canada
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31
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Deane AM, Hodgson CL, Young P, Little L, Singh V, Poole A, Young M, Mackle D, Lange K, Williams P, Peake SL, Chapman MJ, Iwashyna TJ. The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study. Anaesth Intensive Care 2017; 45:476-484. [PMID: 28673218 DOI: 10.1177/0310057x1704500411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.
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Affiliation(s)
| | | | | | | | - V Singh
- The Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Melbourne, Victoria
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32
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Gluck S, Chapple LAS, Chapman MJ, Iwashyna TJ, Deane AM. A scoping review of use of wearable devices to evaluate outcomes in survivors of critical illness. CRIT CARE RESUSC 2017; 19:197-204. [PMID: 28866969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Wearable devices using new technology may be a cost-effective method to assess functional outcomes in survivors of critical illness. Our primary objective was to review the extent to which wearable devices such as smartphones, pedometers, accelerometers and global positioning systems have been used to evaluate outcomes in survivors of an intensive care unit admission. DESIGN We included studies of patients surviving an ICU admission and which measured outcomes using wearable devices. We performed a scoping review of studies found by searching the CINAHL, Embase, MEDLINE and PubMed databases. RESULTS The seven studies we identified were published in or after 2012 and were predominantly descriptive (n = 6) with one randomised controlled trial. All studies described outcomes in cohorts of relatively few participants (range, 11-51 participants). Duration to follow-up was mostly short, at a median time of 3 months after ICU discharge (range, in-hospital to 27 years). All studies used accelerometers to monitor patient movement: physical activity (n = 5), sleep quality (n = 1), and infant movement (n = 1). The accelerometers were bi-axial (n = 3), uni-axial (n = 2) combined uni-axial (n = 1) and tri-axial (n = 1). Common outcomes evaluated were the number of participants walking for < 30 min/day, mean daily step count and walking speed. CONCLUSIONS Wearable devices have infrequently been used to measure physical activity in survivors of critical illness and all identified studies were published recently, which suggests that the use of wearable devices for research may be increasing. To date, only accelerometry has been reported, and the wide variation in methodologies used and the outcomes measured limits synthesis of these data.
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Affiliation(s)
- Samuel Gluck
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, Mich, United States
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
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33
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Maiden MJ, Otto S, Brealey JK, Finnis ME, Chapman MJ, Kuchel TR, Nash CH, Edwards J, Bellomo R. Structure and Function of the Kidney in Septic Shock. A Prospective Controlled Experimental Study. Am J Respir Crit Care Med 2017; 194:692-700. [PMID: 26967568 DOI: 10.1164/rccm.201511-2285oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE It is unclear how septic shock causes acute kidney injury (AKI) and whether this is associated with histological change. OBJECTIVES We aimed to determine the nature and extent of changes in renal structure and function over time in an ovine model of septic shock. METHODS Fifteen sheep were instrumented with a renal artery flow probe and renal vein cannula. Ten were given intravenous Escherichia coli to induce septic shock, and five acted as controls. Animals were mechanically ventilated for 48 hours, while receiving protocol-guided parenteral fluids and a norepinephrine infusion to maintain mean arterial pressure. Renal biopsies were taken every 24 hours or whenever animals were oliguric for 2 hours. A renal pathologist, blinded to tissue source, systematically quantified histological appearance by light and electron microscopy for 31 prespecified structural changes. MEASUREMENTS AND MAIN RESULTS Sheep given E. coli developed septic shock, oliguria, increased serum creatinine, and reduced creatinine clearance (AKI), but there were no changes over time in renal blood flow between groups (P > 0.30) or over time within groups (P > 0.50). Renal oxygen consumption increased only in nonseptic animals (P = 0.01), but there was no between-group difference in renal lactate flux (P > 0.50). There was little structural disturbance in all biopsies and, although some cellular appearances changed over time, the only difference between septic and nonseptic animals was mesangial expansion on electron microscopy. CONCLUSIONS In an intensive care-supported model of gram-negative septic shock, early AKI was not associated with changes in renal blood flow, oxygen delivery, or histological appearance. Other mechanisms must contribute to septic AKI.
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Affiliation(s)
- Matthew J Maiden
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Sophia Otto
- 3 Department of Pathology, SA Pathology, Adelaide, Australia
| | - John K Brealey
- 3 Department of Pathology, SA Pathology, Adelaide, Australia
| | - Mark E Finnis
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Marianne J Chapman
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Tim R Kuchel
- 4 Preclinical, Imaging and Research Laboratories, South Australian Health and Medical Research Institute, Gilles Plains, Australia; and
| | - Coralie H Nash
- 2 Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Jason Edwards
- 1 Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
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Selvanderan SP, Summers MJ, Finnis ME, Plummer MP, Ali Abdelhamid Y, Anderson MB, Chapman MJ, Rayner CK, Deane AM. Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Crit Care Med 2017; 44:1842-50. [PMID: 27635481 DOI: 10.1097/ccm.0000000000001819] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration. DESIGN Prospective randomized double-blind parallel-group study. SETTING University-affiliated mixed medical-surgical ICU. PATIENTS Mechanically ventilated critically ill patients suitable for enteral nutrition. INTERVENTIONS We randomly assigned patients to receive either daily IV placebo or pantoprazole. MEASUREMENTS AND MAIN RESULTS Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97-2.90]; p = 0.06). CONCLUSIONS We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.
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Affiliation(s)
- Shane P Selvanderan
- 1Discipline of Acute Care Medicine, the University of Adelaide, Adelaide, SA, Australia.2Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia.3National Health and Medical Research Council of Australia Centre for Research Excellence in Nutritional Physiology and Outcomes, Adelaide, SA, Australia.4Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia.5Discipline of Medicine, the University of Adelaide, Adelaide, SA, Australia
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Chapple LAS, Deane AM, Williams LT, Strickland R, Schultz C, Lange K, Heyland DK, Chapman MJ. Longitudinal changes in anthropometrics and impact on self-reported physical function after traumatic brain injury. CRIT CARE RESUSC 2017; 19:29-36. [PMID: 28215129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND AIMS Patients admitted to the ICU with a traumatic brain injury (TBI) are at risk of muscle wasting but this has not been quantified. Our aims were to describe longitudinal changes in anthropometrical data, compare the accuracy of non-invasive methodologies to the validated dual-energy x-ray absorptiometry (DXA), and assess the relationships between anthropometrical data and self-reported physical function. METHODS In a prospective observational study, we recruited patients admitted to the ICU with a moderate-to-severe TBI over 12 months. Anthropometric measurements included the subjective global assessment (SGA), bodyweight and ultrasoundderived quadriceps muscle layer thickness (QMLT), which we performed weekly in hospital and 3 months after admission. We assessed total body composition using DXA within 7 days of ICU discharge, and compared the total lean muscle mass with ultrasound-derived QMLT taken within 5 days of the DXA measurement. We assessed functional outcomes at 3 months using the physical component score of the Short Form-36 (SF- 36) and the Extended Glasgow Outcome Scale (GOS-E). RESULTS Thirty-seven patients were included, with a mean age of 45 years (SD, 16 years), and 87% were men. Participants were admitted to the ICU for a mean of 13 days (IQR, 6-18 days) and to hospital for a mean of 38 days (IQR, 19-52 days). They had significant weight loss in hospital (mean, 4.9% [SD, 7.7%]; P = 0.001). Malnutrition, measured with the SGA, was twice as prevalent at hospital discharge than at admission (P = 0.005). A reduction in QMLT occurred in the ICU but stabilised after ICU discharge. DXA-derived total lean mass taken within 7 days of ICU discharge strongly correlated with ultrasound-derived QMLT taken within 5 days of DXA measurements (ρ = 0.74, P = 0.037). Improvements in self-reported physical function, using the SF- 36 and GOS-E at 3 months, were associated with a greater QMLT at hospital discharge (SF-36: ρ = 0.536, P = 0.010; GOS-E: ρ = 0.595, P = 0.003, n = 23) and at 3 months (SF-36: ρ = 0.658, P = 0.020; GOS-E: ρ = 0.642, P = 0.025, n = 12). CONCLUSIONS Patients with a TBI lose muscle thickness while in the ICU but the trajectory of loss stabilises after ICU discharge. Ultrasound-derived QMLT is related to total lean mass and physical function after discharge. Further studies are needed to confirm that ultrasound measurement of QMLT is a useful surrogate measure of muscle mass and functional outcomes after trauma and critical illness.
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Affiliation(s)
- Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Gold Coast, QLD, Australia
| | | | - Chris Schultz
- Department of Nuclear Medicine and Bone Densitometry, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kylie Lange
- Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, National Health and Medical Research Council, Adelaide, SA, Australia
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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Miller A, Deane AM, Plummer MP, Cousins CE, Chapple LAS, Horowitz M, Chapman MJ. Exogenous glucagon-like peptide-1 attenuates glucose absorption and reduces blood glucose concentration after small intestinal glucose delivery in critical illness. CRIT CARE RESUSC 2017; 19:37-42. [PMID: 28215130 DOI: pmid/28215130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effect of exogenous glucagonlike peptide-1 (GLP-1) on small intestinal glucose absorption and blood glucose concentrations during critical illness. DESIGN, SETTING AND PARTICIPANTS A prospective, blinded, placebo-controlled, cross-over, randomised trial in a mixed medical-surgical adult intensive care unit, with 12 mechanically ventilated critically ill patients, who were suitable for receiving small intestinal nutrient. INTERVENTIONS On consecutive days, in a randomised order, participants received intravenous GLP-1 (1.2 pmol/ kg/min) or placebo (0.9% saline) as a continuous infusion over 270 minutes. After 6 hours of fasting, intravenous infusions of GLP-1 or placebo began at T = -30 min (in which T = time), with the infusion maintained at a constant rate until study completion at T = 240 min. At T = 0 min, a 100 mL bolus of mixed liquid nutrient meal (1 kcal/mL) containing 3 g of 3-O-methyl-D-gluco-pyranose (3-OMG), a marker of glucose absorption, was administered directly into the small intestine, via a post-pyloric catheter, over 6 minutes. MAIN OUTCOME MEASURES Blood samples were taken at regular intervals for the measurement of plasma glucose and 3-OMG concentrations. RESULTS Intravenous GLP-1 attenuated initial small intestinal glucose absorption (mean area under the curve [AUC]0-30 for 3-OMG: GLP-1 group, 4.4 mmol/L/min [SEM, 0.9 mmol/L/min] v placebo group, 6.5 mmol/L/min [SEM, 1.0 mmol/L/min]; P = 0.01), overall small intestinal glucose absorption (mean AUC0-240 for 3-OMG: GLP-1, 68.2 mmol/L/ min [SEM, 4.7 mmol/L/min] v placebo, 77.7 mmol/L/min [SEM, 4.4 mmol/lLmin]; P = 0.02), small intestinal glucose absorption and overall blood glucose concentration (mean AUC0-240 for blood glucose: GLP-1, 2062 mmol/L/min [SEM, 111 mmol/L/min] v placebo 2328 mmol/L/min [SEM, 145 mmol/L/min]; P = 0.005). CONCLUSIONS Short-term administration of exogenous GLP-1 reduces small intestinal glucose absorption for up to 4 hours during critical illness. This is likely to be an additional mechanism for the glucose-lowering effect of this agent.
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Affiliation(s)
| | - Adam M Deane
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | | | | | - Michael Horowitz
- NHMRC Centre of Research Excellence in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, SA, Australia
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Marty FM, Vidal-Puigserver J, Clark C, Gupta SK, Merino E, Garot D, Chapman MJ, Jacobs F, Rodriguez-Noriega E, Husa P, Shortino D, Watson HA, Yates PJ, Peppercorn AF. Intravenous zanamivir or oral oseltamivir for hospitalised patients with influenza: an international, randomised, double-blind, double-dummy, phase 3 trial. Lancet Respir Med 2017; 5:135-146. [PMID: 28094141 DOI: 10.1016/s2213-2600(16)30435-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neuraminidase inhibitors are effective for the treatment of acute uncomplicated influenza. However, there is an unmet need for intravenous treatment for patients admitted to hospital with severe influenza. We studied whether intravenous zanamivir was a suitable treatment in this setting. METHODS In this international, randomised, double-blind, double-dummy, phase 3 trial, we recruited patients aged 16 years or older with severe influenza admitted to 97 hospitals from 26 countries. We randomly assigned patients (1:1:1 stratified by symptom onset ≤4 days or 5-6 days) to receive 300 mg or 600 mg intravenous zanamivir, or standard-of-care (75 mg oral oseltamivir) twice a day for 5-10 days; patients were followed up for 28 days. The randomisation schedule, including stratification, was generated using GlaxoSmithKline's RandAll software. Patients, site study staff, and sponsor were masked to study treatment. The primary endpoint was time to clinical response-a composite of vital sign stabilisation and hospital discharge-in the influenza-positive population. The trial was powered to show an improvement of 1·5 days or greater with 600 mg intravenous zanamivir. Pharmacokinetic, safety, and virology endpoints were also assessed. This trial is registered with ClinicalTrials.gov, number NCT01231620. FINDINGS Between Jan 15, 2011, and Feb 12, 2015, 626 patients were randomly assigned to receive 300 mg intravenous zanamivir (n=201), 600 mg intravenous zanamivir (n=209), or 75 mg oral oseltamivir (n=205) twice a day; 11 patients discontinued the study before receiving any study treatment. 488 (78%) of 626 patients had laboratory-confirmed influenza. Compared with a median time to clinical response of 5·14 days in the 600 mg intravenous zanamivir group, the median time to clinical response was 5·87 days (difference of -0·73 days, 95% CI -1·79 to 0·75; p=0·25) in the 300 mg intravenous zanamivir group and 5·63 days (difference of -0·48 days, 95% CI -2·11 to 0·97; p=0·39) in the oseltamivir group. Four patients with influenza A/H1N1pdm09 in the oseltamivir group developed H275Y resistance mutations. Adverse events were reported in 373 (61%) of treated patients and were similar across treatment groups; the most common adverse events (300 mg intravenous zanamivir, 600 mg intravenous zanamivir, oseltamivir) were diarrhoea (10 [5%], 15 [7%], 14 [7%]), respiratory failure (11 [5%], 14 [7%], 11 [5%]), and constipation (7 [3%], 13 [6%], 10 [5%]). 41 (7%) treated patients died during the study (15 [7%], 15 [7%], 11 [5%]); the most common causes of death were respiratory failure and septic shock. INTERPRETATION Time to clinical response to intravenous zanamivir dosed at 600 mg was not superior to oseltamivir or 300 mg intravenous zanamivir. All treatments had a similar safety profile in hospitalised patients with severe influenza. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Francisco M Marty
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
| | - Joan Vidal-Puigserver
- Servei d'Urgències, Hospital Universitari Son Espases, Palma de Mallorca, Illes Balears, Spain
| | - Carol Clark
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Denis Garot
- Service de Réanimation Polyvalente, Hôpital Bretonneau, Tours, France
| | | | - Frédérique Jacobs
- Infectious Diseases Department, CUB-Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Eduardo Rodriguez-Noriega
- Infectología, Hospital Civil de Guadalajara Fray Antonio Alcalde; Instituto de Patología Infecciosa y Experimental, CUCS, UDG Guadalajara, Jalisco, Mexico
| | - Petr Husa
- Department of Infectious Diseases, Faculty of Medicine, Masaryk University; University Hospital Brno, Czech Republic
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Chapple LS, Deane AM, Lange K, Kranz AJ, Williams LT, Chapman MJ. Weekend days are not required to accurately measure oral intake in hospitalised patients. J Hum Nutr Diet 2016; 30:378-384. [PMID: 27709690 DOI: 10.1111/jhn.12432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Nutrition studies in patients admitted to hospital frequently disregard oral intake because measurement is time-intensive and logistically challenging. In free-living populations, weighed food records (WFR) are the gold-standard and are conducted on weekend and weekdays to capture variations in intake, although this may not translate during hospitalisation. The present study aimed to determine whether oral intake differs between weekends and weekdays in hospitalised patients. METHODS For adult patients initially admitted to the intensive therapy unit with a moderate-severe head injury over a 12-month period, WFR were conducted each week on Tuesday, Thursday and Saturday throughout hospitalisation. Meal components were weighed before and after consumption, and energy and protein intakes were calculated using specialised software. Data are reported as the mean (SD). Differences were assessed using paired t-tests and agreement using Bland-Altman plots. RESULTS Thirty-two patients had WFR collected on 220 days, 68% (n = 149) on weekdays and 32% (n = 71) on weekends. Overall, daily intakes were 5.72 (3.67) MJ [1367 (877) kcal] and 62 (40) g protein. There were no differences in intake across all days (P = 0.937 energy, P = 0.797 protein), nor between weekdays and weekends, in weeks 1-3 of oral intake (all P > 0.1). Limits of agreement between mean intakes across days were wide for energy [range -11.20 to 9.55 MJ (-2680 to 2283 kcal)] and protein (range -125 to 110 g). CONCLUSIONS Grouped energy and protein intakes from WFR in hospitalised patients are similar on weekdays and weekends, although large intra-patient variations occur. Future quantification of oral intake during hospitalisation should include as many days as feasible, although not necessarily weekend days, to reflect true intake.
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Affiliation(s)
- L S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.,National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, SA, Australia
| | - A M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.,National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, SA, Australia.,Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - K Lange
- National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, SA, Australia
| | - A J Kranz
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - L T Williams
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia
| | - M J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.,National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, SA, Australia.,Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, Adelaide, SA, Australia
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Plummer MP, Kar P, Cousins CE, Hausken T, Lange K, Chapman MJ, Jones KL, Horowitz M, Deane AM. Critical Illness Is Associated With Impaired Gallbladder Emptying as Assessed by 3D Ultrasound. Crit Care Med 2016; 44:e790-6. [PMID: 27071067 DOI: 10.1097/ccm.0000000000001715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To quantify gallbladder dysfunction during critical illness. DESIGN Prospective observational comparison study of nutrient-stimulated gallbladder emptying in health and critical illness. SETTING Single-centre mixed medical/surgical ICU. PATIENTS Twenty-four mechanically ventilated critically ill patients suitable to receive enteral nutrition were compared with 12 healthy subjects. INTERVENTIONS Participants were studied after an 8-hour fast. Between 0 and 120 minutes, high-fat nutrient (20% intralipid) was infused via a postpyloric catheter into the duodenum at 2 kcal/min. MEASUREMENTS AND MAIN RESULTS Three-dimensional images of the gallbladder were acquired at 30-minute intervals from -30 to 180 minutes. Ejection fraction (%) was calculated as changes between 0 and 120 minutes. Blood samples were obtained at 30-minute intervals for plasma cholecystokinin. Data are mean (SD) or median [interquartile range]. In the critically ill, fasting gallbladder volumes (critically ill, 61 mL [36-100 mL] vs healthy, 22 mL [15-25] mL; p < 0.001] and wall thickness (0.45 mm [0.15 mm] vs 0.26 mm [0.08 mm]; p < 0.001] were substantially greater, and sludge was evident in the majority of patients (71% vs 0%). Nutrient-stimulated emptying was incomplete in the critically ill after 120 minutes but was essentially complete in the healthy individuals (22 mL [9-66 mL] vs 4 mL [3-5 mL]; p < 0.01]. In five critically ill patients (21%), there was no change in gallbladder volume in response to nutrient, and overall ejection fraction was reduced in the critically ill (50% [8-83%] vs 77 [72-84%]; p = 0.01]. There were no differences in fasting or incremental cholecystokinin concentrations. CONCLUSIONS Fasted critically ill patients have larger, thicker-walled gallbladders than healthy subjects and nutrient-stimulated gallbladder emptying is impaired with "gallbladder paresis" occurring in approximately 20%.
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Affiliation(s)
- Mark P Plummer
- 1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Medicine, Haukeland University Hospital, Bergen, Norway.4Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
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Kar P, Plummer MP, Bellomo R, Jenkins AJ, Januszewski AS, Chapman MJ, Jones KL, Horowitz M, Deane AM. Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. Crit Care Med 2016; 44:1695-703. [PMID: 27315191 DOI: 10.1097/ccm.0000000000001815] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a " liberal" approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe. DESIGN Prospective, open-label, sequential-period exploratory study. SETTING Medical-surgical ICU. PATIENTS During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). INTERVENTION During the "standard care" period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the "liberal" period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L. MEASUREMENTS AND MAIN RESULTS Time-weighted mean glucose concentrations and the number and duration of moderate (< 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucoseday 0-7, standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L; p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L; p < 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19-1.13]; p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%]; p < 0.01). Biomarker data and clinical outcomes were similar. CONCLUSIONS In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia.
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Affiliation(s)
- Palash Kar
- 1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.4School of Medicine, The University of Melbourne, Melbourne, VIC, Australia.5Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.6National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.7National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, SA, Australia.8Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
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Kar P, Plummer MP, Chapman MJ, Cousins CE, Lange K, Horowitz M, Jones KL, Deane AM. Energy-Dense Formulae May Slow Gastric Emptying in the Critically Ill. JPEN J Parenter Enteral Nutr 2016; 40:1050-6. [PMID: 26038421 DOI: 10.1177/0148607115588333] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/11/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. "Energy-dense formulae" (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy-dense formulae in critically ill patients. METHODS In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100-mL "meal" containing either standard calories (1 kcal/mL) or concentrated calories (energy-dense formulae; 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. RESULTS Forty patients were studied (n = 18, energy-dense formulae; n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy-dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy-dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. CONCLUSIONS In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.
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Affiliation(s)
- Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | | | - Kylie Lange
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia National Health and Medical Research Council, Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
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Chapman MJ, Deane AM, O'Connor SL, Nguyen NQ, Fraser RJL, Richards DB, Hacquoil KE, Vasist Johnson LS, Barton ME, Dukes GE. The effect of camicinal (GSK962040), a motilin agonist, on gastric emptying and glucose absorption in feed-intolerant critically ill patients: a randomized, blinded, placebo-controlled, clinical trial. Crit Care 2016; 20:232. [PMID: 27476581 PMCID: PMC4967996 DOI: 10.1186/s13054-016-1420-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/20/2016] [Indexed: 02/08/2023]
Abstract
Background The promotility agents currently available to treat gastroparesis and feed intolerance in the critically ill are limited by adverse effects. The aim of this study was to assess the pharmacodynamic effects and pharmacokinetics of single doses of the novel gastric promotility agent motilin agonist camicinal (GSK962040) in critically ill feed-intolerant patients. Methods A prospective, randomized, double-blind, parallel-group, placebo-controlled, study was performed in mechanically ventilated feed-intolerant patients [median age 55 (19–84), 73 % male, APACHE II score 18 (5–37) with a gastric residual volume ≥200 mL]. Gastric emptying and glucose absorption were measured both pre- and post-treatment after intragastric administration of 50 mg (n = 15) camicinal and placebo (n = 8) using the 13C-octanoic acid breath test (BTt1/2), acetaminophen concentrations, and 3-O-methyl glucose concentrations respectively. Results Following 50 mg enteral camicinal, there was a trend to accelerated gastric emptying [adjusted geometric means: pre-treatment BTt1/2 117 minutes vs. post- treatment 76 minutes; 95 % confidence intervals (CI; 0.39, 1.08) and increased glucose absorption (AUC240min pre-treatment: 28.63 mmol.min/L vs. post-treatment: 71.63 mmol.min/L; 95 % CI (1.68, 3.72)]. When two patients who did not have detectable plasma concentrations of camicinal were excluded from analysis, camicinal accelerated gastric emptying (adjusted geometric means: pre-treatment BTt1/2 121 minutes vs. post-treatment 65 minutes 95 % CI (0.32, 0.91) and increased glucose absorption (AUC240min pre-treatment: 33.04 mmol.min/L vs. post-treatment: 74.59 mmol.min/L; 95 % CI (1.478, 3.449). In those patients receiving placebo gastric emptying was similar pre- and post-treatment. Conclusions When absorbed, a single enteral dose of camicinal (50 mg) accelerates gastric emptying and increases glucose absorption in feed-intolerant critically ill patients. Trial registration The study protocol was registered with the US NIH clinicaltrials.gov on 23 December 2009 (Identifier NCT01039805).
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Affiliation(s)
- Marianne J Chapman
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia. .,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.
| | - Adam M Deane
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Stephanie L O'Connor
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Nam Q Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Robert J L Fraser
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, Australia
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Reid DB, Chapple LS, O'Connor SN, Bellomo R, Buhr H, Chapman MJ, Davies AR, Eastwood GM, Ferrie S, Lange K, McIntyre J, Needham DM, Peake SL, Rai S, Ridley EJ, Rodgers H, Deane AM. The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission. Anaesth Intensive Care 2016; 44:406-12. [PMID: 27246942 DOI: 10.1177/0310057x1604400309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.
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Affiliation(s)
- D B Reid
- Intensive Care Registrar, Royal Adelaide Hospital, Adelaide, South Australia
| | - L S Chapple
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland
| | - S N O'Connor
- Research Manager, Intensive Care Unit, Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia
| | - R Bellomo
- Intensive Care Consultant, Austin Hospital, Melbourne, Victoria
| | - H Buhr
- Research Manager, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - M J Chapman
- Director of Research, Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - A R Davies
- Research Fellow, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - G M Eastwood
- Research Manager, Department of Intensive Care, Austin Hospital, Melbourne, Victoria
| | - S Ferrie
- Critical Care Dietitian, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - K Lange
- Biostatistician, Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - J McIntyre
- Research Coordinator, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - D M Needham
- Medical Director, Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, USA
| | - S L Peake
- Senior Intensive Care Clinician, Discipline of Acute Care Medicine, University of Adelaide, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - S Rai
- Intensive Care Specialist, The Canberra Hospital, Canberra, Australian Capital Territory
| | - E J Ridley
- Nutrition Program Manager, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - H Rodgers
- Research Coordinator, The Canberra Hospital, Canberra, Australian Capital Territory
| | - A M Deane
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
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Pryor LN, Ward EC, Cornwell PL, O'Connor SN, Chapman MJ. Establishing phonation using the Blom®tracheostomy tube system: A report of three cases post cervical spinal cord injury. Speech, Language and Hearing 2016. [DOI: 10.1080/2050571x.2016.1196035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Liew VY, Chapman MJ, Nguyen NQ, Cousins CE, Plummer MP, Chapple LAS, Abdelhamid YA, Manton ND, Swalling A, Sutton-Smith P, Burt AD, Deane AM. A prospective observational study of the effect of critical illness on ultrastructural and microscopic morphology of duodenal mucosa. CRIT CARE RESUSC 2016; 18:102-108. [PMID: 27242108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Disturbed intestinal barrier function due to 'leaky' tight junctions may cause secondary sepsis via paracellular translocation across the gut wall. Our objective was to describe the effects of critical illness on duodenal morphology and ultrastructure. DESIGN, SETTING AND PARTICIPANTS Prospective observational study of 12 mechanically ventilated critically ill patients in an intensive care unit and 15 control participants in an outpatient endoscopy suite. INTERVENTION We took six endoscopic biopsy samples of the duodenum from each participant for analysis by electron and light microscopy. MAIN OUTCOME MEASURES Our primary outcome was tight junction morphology, examined with electron microscopy. Secondary outcomes were microvillus length and density, vascular endothelium morphology and mitochondrial density and morphology, examined with electron microscopy, and morphology examined with light microscopy. RESULTS We observed no abnormalities of tight junction ultrastructure in either group. There was a tendency towards shorter microvilli in the critically ill group: mean length in critically ill patients, 1.17 µm (interquartile range [IQR], 1.05-1.60 µm) v mean length in control patients, 1.58 µm (IQR, 1.30-1.72 µm); P = 0.07. There was a tendency towards less dense microvilli in the critically ill group: mean density in critically ill patients, 7.29 microvilli/µm (IQR, 6.83-8.05 microvilli/µm) v mean density in control patients, 8.23 microvilli/µm (IQR, 7.34-9.11 microvilli/µm); P = 0.07. Vascular endothelium appeared normal in all critically ill patients and abnormal in one control participant. Abnormal mitochondrial morphology was noted in one critically ill patient and one control participant, and no differences were seen in mitochondrial density. Using light microscopy, we saw more apoptotic cells in the critically ill patients (P = 0.018), but villus height, crypt depth and lymphocyte density were normal. CONCLUSIONS We did not detect any morphological abnormalities of duodenal tight junctions in critically ill patients. Our results should be interpreted with caution because of the small sample population, but our observations challenge the concept that paracellular translocation facilitates secondary sepsis.
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Affiliation(s)
- Victor Y Liew
- Discipline of Acute Care Medicine, University of Adelaide, SA, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, SA, Australia
| | - Nam Q Nguyen
- Centre for Research Excellence in Nutritional Physiology, University of Adelaide, Adelaide, SA, Australia
| | | | - Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, SA, Australia
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, SA, Australia
| | | | - Nicholas D Manton
- Department of Anatomical Pathology, SA Pathology, Adelaide, SA, Australia
| | - Adam Swalling
- Department of Anatomical Pathology, SA Pathology, Adelaide, SA, Australia
| | - Peter Sutton-Smith
- Department of Anatomical Pathology, SA Pathology, Adelaide, SA, Australia
| | - Alastair D Burt
- Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, SA, Australia.
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46
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Plummer MP, Kar P, Cousins CE, Lange K, Chapman MJ, Nauck MA, Horowitz M, Meier JJ, Deane AM. The insulinotropic effect of pulsatile compared with continuous intravenous delivery of GLP-1. Diabetologia 2016; 59:966-9. [PMID: 26831299 DOI: 10.1007/s00125-016-3878-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/06/2016] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS In healthy individuals, both insulin and glucagon-like peptide 1 (GLP-1) are secreted in a pulsatile fashion. Insulin has greater glucose-lowering properties when administered in pulses compared with a constant i.v. infusion. The primary aim of this randomised double-dummy cross-over study was to compare the insulinotropic response to pulsatile and continuous i.v. infusions of equivalent doses of GLP-1. METHODS Twelve healthy participants aged 18-35 years were randomised to three different treatments on separate days: a continuous infusion day (GLP-1 at 0.6 pmol kg(-1) min(-1) [1 ml/min] and a 1 ml placebo bolus every 6 min); a pulsatile infusion day (placebo at 1 ml/min and a 3.6 pmol/kg GLP-1 bolus every 6 min); and a placebo day (placebo at 1 ml/min and a 1 ml placebo bolus every 6 min). Between 45 and 120 min, a hyperglycaemic clamp was used to maintain blood glucose at 9 mmol/l. Venous blood glucose and plasma insulin concentrations were measured every 5 min from 0 to 45 min and every 1 min from 45 to 120 min; plasma glucagon was measured every 15 min. The order of treatment was randomised by the Pharmacy Department and both study investigators and participants were blinded to the treatment arm. The dextrose requirement and glucagon data were analysed using repeated measures ANOVA and insulin data were analysed with a linear mixed effects maximum likelihood model. RESULTS Continuous and pulsatile infusions of GLP-1 increased the dextrose requirement by ~threefold (p < 0.001) and increased insulin secretion by ~ninefold (p < 0.001). There was no difference in the effect of both treatments. Although hyperglycaemia reduced plasma glucagon concentrations, there was no difference between the treatment days. CONCLUSIONS/INTERPRETATION In healthy individuals, pulsatile and continuous administration of i.v. GLP-1 appears to have comparable insulinotropic effects. TRIAL REGISTRATION ACTRN12612001040853 FUNDING: This study was supported by the National Health and Medical Research Council (NHMRC) of Australia.
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Affiliation(s)
- Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
- Intensive Care Research Unit, Level 4 Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Research Unit, Level 4 Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Caroline E Cousins
- Intensive Care Research Unit, Level 4 Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Kylie Lange
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Research Unit, Level 4 Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
| | - Michael A Nauck
- Division of Diabetes and GI Endocrinology, University Hospital St Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Juris J Meier
- Division of Diabetes and GI Endocrinology, University Hospital St Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Research Unit, Level 4 Emergency Block, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
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Abstract
Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.
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Affiliation(s)
- Y Ali Abdelhamid
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - M J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
| | - A M Deane
- Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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48
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Pryor LN, Ward EC, Cornwell PL, O'Connor SN, Chapman MJ. Clinical indicators associated with successful tracheostomy cuff deflation. Aust Crit Care 2016; 29:132-7. [PMID: 26920443 DOI: 10.1016/j.aucc.2016.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/09/2015] [Accepted: 01/12/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tracheostomy cuff deflation is a necessary stage of the decannulation pathway, yet the optimal clinical indicators to guide successful cuff deflation are unknown. OBJECTIVES The study aims were to identify (1) the proportion of patients tolerating continuous cuff deflation at first attempt; (2) the clinical observations associated with cuff deflation success or failure, including volume of above cuff secretions and (3) the predictive capacity of these observations within a heterogeneous cohort. METHODS A retrospective review of 113 acutely tracheostomised patients with a subglottic suction tube in situ was conducted. RESULTS Ninety-five percent of patients (n=107) achieved continuous cuff deflation on the first attempt. The clinical observations recorded as present in the 24h preceding cuff deflation included: (1) medical stability, (2) respiratory stability, (3) fraction of inspired oxygen ≤0.4, (4) tracheal suction ≤1-2 hourly, (5) sputum thin and easy to suction, (6) sputum clear or white, (7) ≥moderate cough strength, (8) above cuff secretions ≤1ml per hour and (9) alertness≥eyes open to voice. Using the presence of all 9 indicators as predictors of successful cuff deflation tolerance, specificity and positive predictive value were 100%, although sensitivity was only 77% and negative predictive value 19%. Refinement to a set of 3 clinically driven criteria (medical and respiratory stability, above cuff secretions ≤1ml/h) provided high specificity (100%), sensitivity (95%), positive predictive value (100%) and an improved negative predictive value (55%). CONCLUSIONS Key criteria can help guide clinical decision-making on patient readiness for cuff deflation.
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Affiliation(s)
- Lee N Pryor
- Royal Adelaide Hospital, Intensive Care Unit, SA, Australia; The University of Queensland, School of Health & Rehabilitation Sciences, QLD, Australia.
| | - Elizabeth C Ward
- The University of Queensland, School of Health & Rehabilitation Sciences, QLD, Australia; Centre for Functioning & Health Research (CFAHR), QLD, Australia
| | - Petrea L Cornwell
- The Prince Charles Hospital, Metro North Hospital and Health Service, QLD, Australia; School of Applied Psychology, Menzies Health Institute Queensland, Griffith University, QLD, Australia
| | - Stephanie N O'Connor
- Royal Adelaide Hospital, Intensive Care Unit, SA, Australia; The University of Adelaide, School of Medicine, SA, Australia
| | - Marianne J Chapman
- Royal Adelaide Hospital, Intensive Care Unit, SA, Australia; The University of Adelaide, School of Medicine, SA, Australia
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49
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Chapple LAS, Deane AM, Heyland DK, Lange K, Kranz AJ, Williams LT, Chapman MJ. Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury. Clin Nutr 2016; 35:1315-1322. [PMID: 26949198 DOI: 10.1016/j.clnu.2016.02.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/01/2016] [Accepted: 02/10/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Patients with traumatic brain injury (TBI) experience considerable energy and protein deficits in the intensive care unit (ICU) and these are associated with adverse outcomes. However, nutrition delivery after ICU discharge during ward-based care, particularly from oral diet, has not been measured. This study aimed to quantify energy and protein delivery and deficits over the entire hospitalization for critically ill TBI patients. METHODS Consecutively admitted adult patients with a moderate-severe TBI (Glasgow Coma Scale 3-12) over 12 months were eligible. Observational data on energy and protein delivered from all routes were collected until hospital discharge or day 90 and compared to dietician prescriptions. Oral intake was quantified using weighed food records on three pre-specified days each week. Data are mean (SD) unless indicated. Cumulative deficit is the mean absolute difference between intake and estimated requirements. RESULTS Thirty-seven patients [45.3 (15.8) years; 87% male; median APACHE II 18 (IQR: 14-22)] were studied for 1512 days. Median duration of ICU and ward-based stay was 13.4 (IQR: 6.4-17.9) and 19.9 (9.6-32.0) days, respectively. Over the entire hospitalization patients had a cumulative deficit of 18,242 (16,642) kcal and 1315 (1028) g protein. Energy and protein intakes were less in ICU than the ward (1798 (800) vs 1980 (915) kcal/day, p = 0.015; 79 (47) vs 89 (41) g/day protein, p = 0.001). Energy deficits were almost two-fold greater in patients exclusively receiving nutrition orally than tube-fed (806 (616) vs 445 (567) kcal/day, p = 0.016) while protein deficits were similar (40 (5) vs 37 (6) g/day, p = 0.616). Primary reasons for interruptions to enteral and oral nutrition were fasting for surgery/procedures and patient-related reasons, respectively. CONCLUSIONS Patients admitted to ICU with a TBI have energy and protein deficits that persist after ICU discharge, leading to considerable shortfalls over the entire hospitalization. Patients ingesting nutrition orally are at particular risk of energy deficit.
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Affiliation(s)
- Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia; Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
| | - Kylie Lange
- Discipline of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia.
| | - Amelia J Kranz
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia.
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Queensland, Australia.
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia; Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
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Declercq B, Deane AM, Wang M, Chapman MJ, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol in critically ill surgical patients: a multicentre prospective evaluation. Anaesth Intensive Care 2016; 44:93-8. [PMID: 26673594 DOI: 10.1177/0310057x1604400114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Suboptimal levels of feeding in critically ill patients are associated with poor clinical outcomes. The Enhanced Protein-Energy Provision via the Enteral Route Feeding (PEPuP) protocol was developed to improve nutritional delivery in the critically ill and has been studied in several hospitals. However, the experience with this protocol in surgical patients is limited to date. The objective of this analysis was to describe the experience with this protocol in surgical patients. We analysed observational patient data obtained from the 2013 International Nutrition Survey. We compared nutritional practices and outcomes of patients admitted for surgical and medical reasons to ICUs in sites that implemented the PEPuP protocol. We used surgical ICU patients in non-PEPuP sites as a concurrent control group. In sites that implemented the PEPuP protocol, surgical patients received a smaller proportion of prescribed calories (43% versus 61%, P=0.004) and protein (38% versus 57%, P=0.002) compared to medical patients. When compared to the cohort of surgical patients from control sites, the surgical patients from PEPuP sites received similar amounts of calories and protein. Although surgical PEPuP patients were more likely to receive trophic and volume-based feeds compared to surgical patients in control sites, other aspects of the PEPuP protocol were not adequately implemented. We conclude that nutritional delivery to surgical patients remains inadequate and the PEPuP protocol seems ineffective in improving nutritional intake in this population. Further research to determine methods of optimising PEPuP protocol implementation and adherence in surgery patients is needed.
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Affiliation(s)
- B Declercq
- Royal Adelaide Hospital, North Terrace, Adelaide, South Australia
| | - A M Deane
- Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - M Wang
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - M J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, and Discipline of Acute Care Medicine, North Terrace, Adelaide, South Australia
| | - D K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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