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Mohsen G, Peisker H, Gutbrod K, Stoppe C, Duerr GD, Velten M. Storage duration of human blood samples for fatty acid concentration analyses - How long is too long? MethodsX 2024; 12:102564. [PMID: 38299039 PMCID: PMC10828803 DOI: 10.1016/j.mex.2024.102564] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Polyunsaturated fatty acids such as DHA have known anti-inflammatory properties. The therapeutic implication highlights the importance of accurate serum measurements. Sample preservation is challenging when performed parallel to the clinical obligations. Impact of time between sample collection and processing regarding concentration alterations of fatty acids in human blood remains to be elucidated. Therefore, more information is required with respect to the stability and storage options in the context of potential degradation and concentration changes. This study investigates the stability of DHA in serum samples over time, given the challenges of timely sample analysis in clinical settings. Blood samples from three patients were collected and stored at +4 °C. Concentrations were analysed between 6 h and 7 days post-collection. Our data indicate that DHA concentrations remained unchanged during the observational period. Our results suggest that storage duration up to 7 days before sample processing does not affect accuracy of the results. DHA measurements is crucial for ongoing and future research in cardiovascular and inflammatory diseases. Our results reveal that DHA stability remains consistent over one week. This information is important for further clinical studies investigating PUFA concentrations, providing researches the option to postpone processing of samples if required along the clinical obligations.
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Affiliation(s)
- Ghaith Mohsen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
| | - Helga Peisker
- Institute of Molecular Physiology and Biotechnology of Plants, University of Bonn, Bonn, Germany
| | - Katharina Gutbrod
- Institute of Molecular Physiology and Biotechnology of Plants, University of Bonn, Bonn, Germany
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Medical Center Mainz, Germany
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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2
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Tagliaferri TL, Rhode S, Munoz P, Simon K, Krüttgen A, Stoppe C, Ruhl T, Beier JP, Horz HP, Kim BS. Antiseptic management of critical wounds: differential bacterial response upon exposure to antiseptics and first insights into antiseptic/phage interactions - experimental studies. Int J Surg 2024:01279778-990000000-01479. [PMID: 38742847 DOI: 10.1097/js9.0000000000001605] [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] [Received: 01/26/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND With the antibiotic crisis, the topical antibacterial control including chronic wounds gains increasing importance. However, little is known regarding tolerance development when bacteria face repetitive exposure to the identical antiseptics as commonly found in clinical practice. MATERIALS AND METHODS We exposed clinical isolates foremost of chronic wounds in vitro to dilutions of two antisepctics used for wound therapy: polyhexanide or octenidine. Adaptive response was determined by growth/kill curves, minimal inhibitory concentration (MIC), and whole genome sequencing. Antiseptic/bacteriophage combinations were studied by liquid-infection assays and bacterial plating. RESULTS Polyhexanide acted stronger against Escherichia coli and Proteus mirabilis while octenidine was more potent against Staphylococcus aureus. Otherwise, the antiseptic efficacy varied across isolates of Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Upon repetitive exposure with constant antiseptic concentrations P. aeruginosa and P. mirabilis adaptation was evident by a reduced lag-phase and a two-fold increased MIC. Under increasing octenidine concentrations, P. aeruginosa adapted to an eightfold higher dosage with mutations in smvA, opgH and kinB affecting an efflux pump, alginate and biofilm formation, respectively. S. aureus adapted to a fourfold increase of polyhexanide with a mutation in the multiple peptide resistance factor MprF, also conferring cross-resistance to daptomycin. Antiseptic/bacteriophage combinations enhanced bacterial inhibition and delayed adaptation. CONCLUSION Different bacterial species/strains respond unequally to low-level antiseptic concentrations. Bacterial adaptation potential at phenotypic and genotypic levels may indicate the necessity for a more nuanced selection of antiseptics. Bacteriophages represent a promising yet underexplored strategy for supporting antiseptic treatment which may be particularly beneficial for the management of critical wounds.
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Affiliation(s)
| | - Sophie Rhode
- Department of Plastic Surgery, Hand Surgery - Burn Center, RWTH Aachen University Hospital, Aachen, Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Medical Center Hamburg-Eppendorf
| | - Priscilla Munoz
- Institute of Medical Microbiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Kevin Simon
- Institute of Medical Microbiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Alex Krüttgen
- Laboratory Diagnostic Center, RWTH Aachen University Hospital, Aachen, Germany
| | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Tim Ruhl
- Department of Plastic Surgery, Hand Surgery - Burn Center, RWTH Aachen University Hospital, Aachen, Germany
| | - Justus P Beier
- Department of Plastic Surgery, Hand Surgery - Burn Center, RWTH Aachen University Hospital, Aachen, Germany
| | - Hans-Peter Horz
- Institute of Medical Microbiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery, Hand Surgery - Burn Center, RWTH Aachen University Hospital, Aachen, Germany
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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Stoppe C, Elke G, Silvstre SCDM, Kappus M. Highlights in the clinical nutrition literature: A critical appraisal of current research. JPEN J Parenter Enteral Nutr 2024; 48:377-388. [PMID: 38310478 DOI: 10.1002/jpen.2599] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 02/05/2024]
Abstract
Within the American Society for Parenteral and Enteral Nutrition (ASPEN), the Physician Engagement Committee (PEC) was created in 2017 by the ASPEN Board of Directors with the goal of growing the physician community both nationally and internationally. The PEC meets each month throughout the year to develop educational and research initiatives. In 2022, the PEC began an initiative to systematically review and evaluate practice-changing literature annually with the overall aim to highlight these studies at the annual ASPEN conferences and to critically discuss the potential clinical implications. The objective of the held meeting session was to present identified key papers in the fields of critical care medicine, gastroenterology and hepatology, and adult internal medicine that were published in 2022, which would complement the knowledge of the pathogenesis, diagnosis, and management of nutrition topics as well as to identify areas of future research. Overall, several large-scale randomized controlled studies were identified in each of these sections, with practice-changing major results. This manuscript summarizes the information that was presented and the discussions that followed.
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Affiliation(s)
- Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Matthew Kappus
- Division of Gastroenterology and Hepatology, Duke University Health, Durham, North Carolina, USA
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Hundeshagen G, Blears E, Mertin V, Day AG, Palackic A, Tapking C, Haug V, Kneser U, Bliesener B, Panayi AC, Aballay A, Depret F, Stoppe C, Heyland DK. Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial. Burns Trauma 2024; 12:tkad063. [PMID: 38650969 PMCID: PMC11033841 DOI: 10.1093/burnst/tkad063] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 04/25/2024]
Abstract
Background Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Elisabeth Blears
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Viktoria Mertin
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada
| | - Alen Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ariel Aballay
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Francois Depret
- Department of Anaesthesiology, Intensive Care Medicine and Burn center, Saint-Louis Hospital, 1 avenue Claude-Vellefaux, 75010, Asistance Publique Hôpitaux de Paris, Paris Cité University, France
| | - Christian Stoppe
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
- University Hospital, Würzburg, Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080 Würzburg, Germany
- Departments of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Augustenburger Platz 1 | 13353, Berlin, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, K7L 2V7 Ontario, Canada
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Stoppe C, Dresen E, de Man A. Micronutrients as therapy in critical illness. Curr Opin Crit Care 2024; 30:178-185. [PMID: 38441190 DOI: 10.1097/mcc.0000000000001133] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Recent large-scale randomized controlled trials (RCTs) challenged current beliefs about the potential role of micronutrients to attenuate the inflammatory response and improve clinical outcomes of critically ill patients. The purpose of this narrative review is to provide an overview and critical discussion about most recent clinical trials, which evaluated the clinical significance of a vitamin C, vitamin D, or selenium administration in critically ill patients. RECENT FINDINGS None of the most recent large-scale RCTs could demonstrate any clinical benefits for a micronutrient administration in ICU patients, whereas a recent RCT indicated harmful effects, if high dose vitamin C was administered in septic patients. Following meta-analyses could not confirm harmful effects for high dose vitamin C in general critically ill patients and indicated benefits in the subgroup of general ICU patients with higher mortality risk. For vitamin D, the most recent large-scale RCT could not demonstrate clinical benefits for critically ill patients, whereas another large-scale RCT is still ongoing. The aggregated and meta-analyzed evidence highlighted a potential role for intravenous vitamin D administration, which encourages further research. In high-risk cardiac surgery patients, a perioperative application of high-dose selenium was unable to improve patients' outcome. The observed increase of selenium levels in the patients' blood did not translate into an increase of antioxidative or anti-inflammatory enzymes, which illuminates the urgent need for more research to identify potential confounding factors. SUMMARY Current data received from most recent large-scale RCTs could not demonstrate clinically meaningful effects of an intervention with either vitamin C, vitamin D, or selenium in critically ill patients. More attention is needed to carefully identify potential confounding factors and to better evaluate the role of timing, duration, and combined strategies.
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Affiliation(s)
- Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Charité Berlin, Berlin, Germany
| | - Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Angelique de Man
- Department of Intensive Care, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Böhm D, Bliesener B, Dieck T, Kruse M, Odenthal T, Stoppe C, Trojan S, Gille J. [Treatment of Burn Shock - The First 24 hours and Beyond]. HANDCHIR MIKROCHIR P 2024; 56:166-171. [PMID: 38412995 DOI: 10.1055/a-2208-8107] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
Acute phase and resuscitation after burn trauma are challenging even for specialised burn centres due to the individual onset and differences compared with other forms of shock. The guidelines of the German Society of Burn Medicine (DGV) cover the scientific basis of modern burn treatment. Nevertheless, uncertainty remains regarding the detailed practical handling. This expert consensus focuses on best practices for the treatment of patients with major burns in specialised burn centres and by clinical first responders. The short version of this expert consensus can be downloaded at: https://verbrennungsmedizin.de/files/dgv_files/pdf/positionspapier/Pos%20Therapie%20des%20Verbrennungsschock%20AK%20Intensivmedizin%202023.pdf.
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Affiliation(s)
- Dorothee Böhm
- Klinik für Handchirurgie, Hochtaunuskliniken Usingen, Usingen, Germany
| | - Björn Bliesener
- Klinik für Hand-, Plastische- und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwigshafen, Germany
| | - Thorben Dieck
- PÄHW, Medizinische Hochschule Hannover, Hannover, Germany
| | - Marianne Kruse
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Tobias Odenthal
- Klinik für Anästhesie, Intensiv-, Rettungs- und Schmerzmedizin, BG Klinikum Hamburg, Hamburg, Germany
| | - Christian Stoppe
- Universitätsklinik Würzburg, University Hospital, Würzburg, Wurzburg, Germany
- Klinik für Anästhesiologie und Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan Trojan
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Köln-Merheim, Klinikum der Universität Witten/ Herdecke, Ostmerheimer Straße 200, 51109 Köln, Köln, Germany
| | - Jochen Gille
- Klinik für Anästhesiologie, Intensiv- und Schmerztherapie, Klinikum St. Georg, Leipzig, Germany
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Patel JJ, Lopez-Delgado JC, Stoppe C, McClave SA. Enteral nutrition in septic shock: a call for a paradigm shift. Curr Opin Crit Care 2024; 30:165-171. [PMID: 38441124 DOI: 10.1097/mcc.0000000000001134] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy. RECENT FINDINGS The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes. SUMMARY The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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Panayi AC, Heyland DK, Stoppe C, Jeschke MG, Didzun O, Matar D, Tapking C, Palackic A, Bliesener B, Harhaus L, Knoedler S, Haug V, Bigdeli AK, Kneser U, Orgill DP, Hundeshagen G. The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial. Crit Care 2024; 28:95. [PMID: 38519972 PMCID: PMC10958907 DOI: 10.1186/s13054-024-04873-8] [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: 01/27/2024] [Accepted: 03/14/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.
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Affiliation(s)
- Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Marc G Jeschke
- Hamilton Health Sciences Research, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Oliver Didzun
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dany Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian Tapking
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Björn Bliesener
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany.
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9
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Huang X, Mao W, Hu X, Qin F, Zhao H, Zhang A, Wang X, Stoppe C, Zhou D, Ke L, Ni H. Immune-Enhancing Treatment among Acute Necrotizing Pancreatitis Patients with Metabolic Abnormalities: A Post Hoc Analysis of a Randomized Clinical Trial. Gut Liver 2024:gnl230326. [PMID: 38356344 DOI: 10.5009/gnl230326] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/08/2023] [Accepted: 11/01/2023] [Indexed: 02/16/2024] Open
Abstract
Background/Aims : Metabolic syndrome is common in patients with acute pancreatitis and its components have been reported to be associated with infectious complications. In this post hoc analysis, we aimed to evaluate whether metabolic abnormalities impact the effect of immune-enhancing thymosin alpha-1 (Tα1) therapy in acute necrotizing pancreatitis (ANP) patients. Methods : All data were obtained from the database for a multicenter randomized clinical trial that evaluated the efficacy of Tα1 in ANP patients. Patients who discontinued the Tα1 treatment prematurely were excluded. The primary outcome was 90-day infected pancreatic necrosis (IPN) after randomization. Three post hoc subgroups were defined based on the presence of hyperglycemia, hypertriglyceridemia, or both at the time of randomization. In each subgroup, the correlation between Tα1 and 90-day IPN was assessed using the Cox proportional-hazards regression model. Multivariable propensity-score methods were used to control potential bias. Results : Overall, 502 participants were included in this post hoc analysis (248 received Tα1 treatment and 254 received matching placebo treatment). Among them, 271 (54.0%) had hyperglycemia, 371 (73.9%) had hypertriglyceridemia and 229 (45.6%) had both. Tα1 therapy was associated with reduced incidence of IPN among patients with hyperglycemia (18.8% vs 29.7%: hazard ratio, 0.80; 95% confidence interval, 0.37 to 0.97; p=0.03), but not in the other subgroups. Additional multivariate regression models using three propensity-score methods yielded similar results. Conclusions : Among ANP patients with hyperglycemia, immune-enhancing Tα1 treatment was associated with a reduced risk of IPN (ClinicalTrials.gov, Registry number: NCT02473406).
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Affiliation(s)
- Xiaofei Huang
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xingxing Hu
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Fengxia Qin
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Nanjing Jiangning District Hospital of Traditional Chinese Medicine, Nanjing, China
| | - Hui Zhao
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Aiping Zhang
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Xinyu Wang
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Charité Berlin, Berlin, Germany
| | - Dandan Zhou
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
| | - Haibin Ni
- Department of Emergency and Critical Care Medicine, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Emergency and Critical Care Medicine, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
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10
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Heuts S, de Heer P, Gabrio A, Bels JLM, Lee ZY, Stoppe C, van Kuijk S, Beishuizen A, de Bie-Dekker A, Fraipont V, Lamote S, Ledoux D, Scheeren C, De Waele E, van Zanten A, Mesotten D, van de Poll MCG. The impact of high versus standard enteral protein provision on functional recovery following intensive care admission: Protocol for a pre-planned secondary Bayesian analysis of the PRECISe trial. Clin Nutr ESPEN 2024; 59:162-170. [PMID: 38220371 DOI: 10.1016/j.clnesp.2023.10.040] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The PRECISe trial is a pragmatic, multicenter randomized controlled trial that evaluates the effect of high versus standard enteral protein provision on functional recovery in adult, mechanically ventilated critically ill patients. The current protocol presents the rationale and analysis plan for an evaluation of the primary and secondary outcomes under the Bayesian framework, with an emphasis on clinically important effect sizes. METHODS This protocol was drafted in agreement with the ROBUST-statement, and is submitted for publication before database lock and primary data analysis. The primary outcome is health-related quality of life as measured by the EQ-5D-5L health utility score and is longitudinally assessed. Secondary outcomes comprise the 6-min walking test and handgrip strength over the entire follow-up period (longitudinal analyses), and 60-day mortality, duration of mechanical ventilation, and EQ-5D-5L health utility scores at 30, 90 and 180 days (cross-sectional). All analyses will primarily be performed under weakly informative priors. When available, informative priors elicited from contemporary literature will also be incorporated under alternative scenarios. In all other cases, objectively formulated skeptical and enthusiastic priors will be defined to assess the robustness of our results. Relevant identified subgroups were: patients with acute kidney injury, severe multi-organ failure and patients with or without sepsis. Results will be presented as absolute risk differences, mean differences, and odds ratios, with accompanying 95% credible intervals. Posterior probabilities will be estimated for clinically important benefit and harm. DISCUSSION The proposed secondary, pre-planned Bayesian analysis of the PRECISe trial will provide additional information on the effects of high protein on functional and clinical outcomes in critically ill patients, such as probabilistic interpretation, probabilities of clinically important effect sizes, and the integration of prior evidence. As such, it will complement the interpretation of the primary outcome as well as several secondary and subgroup analyses.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Pieter de Heer
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Andrea Gabrio
- Department of Methodology and Statistics, Maastricht University, Maastricht, the Netherlands
| | - Julia L M Bels
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Christian Stoppe
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany; University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - Ashley de Bie-Dekker
- Department of Intensive Care Medicine, Catharina Ziekenhuis Eindhoven, Eindhoven, the Netherlands
| | | | - Stoffel Lamote
- Department of Intensive Care Medicine, Academisch Ziekenhuis Groeninge, Kortijk, Belgium
| | - Didier Ledoux
- Sensation and Perception Research Group, GIGA Consciousness, University of Liège, Liège, Belgium; Intensive Care Units, University Hospital of Liège, Liège, Belgium
| | - Clarissa Scheeren
- Department of Intensive Care Medicine, Zuyderland Medisch Centrum, Heerlen, the Netherlands
| | - Elisabeth De Waele
- Department of Nutrition, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Arthur van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Ziekenhuis, Ede, the Netherlands; Division of Human Nutrition & Health, Wageningen University & Research, Wageningen, the Netherlands
| | - Dieter Mesotten
- Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands.
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11
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Dresen E, Modir R, Stoppe C. Nutrition support for patients on mechanical circulatory support. Curr Opin Anaesthesiol 2024; 37:24-34. [PMID: 37865830 DOI: 10.1097/aco.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW No specific guidelines on medical nutrition therapy (MNT) in patients on different types of mechanical circulatory support (MCS) devices yet exist and overall evidence is limited. The purpose of this narrative review is to provide an overview about current existing evidence, which might be of underrecognized importance for the patients' short-term and long-term clinical and functional outcomes. RECENT FINDINGS Patients on MCS inherit substantial metabolic, endocrinologic, inflammatory, and immunologic alterations, and together with the specificities of MCS therapy, technical modalities of respective devices, and concomitant medication, the consideration of individualized MNT approaches is indicated in routine clinical practice. Exemplarily, the evaluation of the patients' individual nutrition status, determination of nutrition targets, progressive increase of energy and protein supply throughout the different phases of disease, prevention of micronutrient deficiencies, implementation of nutrition protocols, appropriate monitoring strategies, and continuous quality improvement are essential elements of MNT in patients on MCS. SUMMARY The importance of MNT for patients on MCS still often remains underrecognized, which might be of particular relevance in view of the significant metabolic alterations, the long treatment period, and severity of illness in these patients. Further research on more targeted MNT approaches in those patients is urgently needed for the generation of evidence-based guidelines for this specific cohort of critically ill patients.
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Affiliation(s)
- Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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12
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Chen Y, Liu Z, Wang Q, Gao F, Xu H, Ke L, Lee ZY, Stoppe C, Heyland DK, Liang F, Lin J. Enhanced exclusive enteral nutrition delivery during the first 7 days is associated with decreased 28-day mortality in critically ill patients with normal lactate level: a post hoc analysis of a multicenter randomized trial. Crit Care 2024; 28:26. [PMID: 38245768 PMCID: PMC10799529 DOI: 10.1186/s13054-024-04813-6] [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: 12/04/2023] [Accepted: 01/17/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition (EN) is often observed during the first week of ICU admission because of the extra costs and safety considerations for early parenteral nutrition. This study aimed to assess the association between nutrition intake and 28-day mortality in critically ill patients receiving exclusive EN. METHODS This is a post hoc analysis of a cluster-randomized clinical trial that assesses the effect of implementing a feeding protocol on mortality in critically ill patients. Patients who stayed in the ICUs for at least 7 days and received exclusive EN were included in this analysis. Multivariable Cox hazard regression models and restricted cubic spline models were used to assess the relationship between the different doses of EN delivery and 28-day mortality. Subgroups with varying lactate levels at enrollment were additionally analyzed to address the potential confounding effect brought in by the presence of shock-related hypoperfusion. RESULTS Overall, 1322 patients were included in the analysis. The median (interquartile range) daily energy and protein delivery during the first week of enrollment were 14.6 (10.3-19.6) kcal/kg and 0.6 (0.4-0.8) g/kg, respectively. An increase of 5 kcal/kg energy delivery was associated with a significant reduction (approximately 14%) in 28-day mortality (adjusted hazard ratio [HR] = 0.865, 95% confidence interval [CI]: 0.768-0.974, P = 0.016). For protein intake, a 0.2 g/kg increase was associated with a similar mortality reduction with an adjusted HR of 0.868 (95% CI 0.770-0.979). However, the benefits associated with enhanced nutrition delivery could be observed in patients with lactate concentration ≤ 2 mmol/L (adjusted HR = 0.804 (95% CI 0.674-0.960) for energy delivery and adjusted HR = 0.804 (95% CI 0.672-0.962) for protein delivery, respectively), but not in those > 2 mmol/L. CONCLUSIONS During the first week of critical illness, enhanced nutrition delivery is associated with reduced mortality in critically ill patients receiving exclusive EN, only for those with lactate concentration ≤ 2 mmol/L. TRIAL REGISTRATION ISRCTN12233792, registered on November 24, 2017.
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Affiliation(s)
- Yizhe Chen
- Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, No. 299 Qingyang Road, Wuxi, 214043 China
| | - Zirui Liu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002 China
| | - Qiuhui Wang
- Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, No. 299 Qingyang Road, Wuxi, 214043 China
| | - Fei Gao
- Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, No. 299 Qingyang Road, Wuxi, 214043 China
| | - Hongyang Xu
- Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, No. 299 Qingyang Road, Wuxi, 214043 China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002 China
- Research Institute of Critical Care Medicine and Emergency Rescue at Nanjing University, Nanjing, China
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité, Berlin, Germany
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité, Berlin, Germany
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queen’s University, Angada 4, Kingston, ON K7L 2V7 Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7 Canada
| | - Fengming Liang
- Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi Medical Center, Nanjing Medical University, No. 299 Qingyang Road, Wuxi, 214043 China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 305 East Zhongshan Road, Nanjing, 210002 China
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13
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Lee ZY, Dresen E, Lew CCH, Bels J, Hill A, Hasan MS, Ke L, van Zanten A, van de Poll MCG, Heyland DK, Stoppe C. The effects of higher versus lower protein delivery in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Crit Care 2024; 28:15. [PMID: 38184658 PMCID: PMC10770947 DOI: 10.1186/s13054-023-04783-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/18/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND A recent large multicentre trial found no difference in clinical outcomes but identified a possibility of increased mortality rates in patients with acute kidney injury (AKI) receiving higher protein. These alarming findings highlighted the urgent need to conduct an updated systematic review and meta-analysis to inform clinical practice. METHODS From personal files, citation searching, and three databases searched up to 29-5-2023, we included randomized controlled trials (RCTs) of adult critically ill patients that compared higher vs lower protein delivery with similar energy delivery between groups and reported clinical and/or patient-centred outcomes. We conducted random-effect meta-analyses and subsequently trial sequential analyses (TSA) to control for type-1 and type-2 errors. The main subgroup analysis investigated studies with and without combined early physical rehabilitation intervention. A subgroup analysis of AKI vs no/not known AKI was also conducted. RESULTS Twenty-three RCTs (n = 3303) with protein delivery of 1.49 ± 0.48 vs 0.92 ± 0.30 g/kg/d were included. Higher protein delivery was not associated with overall mortality (risk ratio [RR]: 0.99, 95% confidence interval [CI] 0.88-1.11; I2 = 0%; 21 studies; low certainty) and other clinical outcomes. In 2 small studies, higher protein combined with early physical rehabilitation showed a trend towards improved self-reported quality-of-life physical function measurements at day-90 (standardized mean difference 0.40, 95% CI - 0.04 to 0.84; I2 = 30%). In the AKI subgroup, higher protein delivery significantly increased mortality (RR 1.42, 95% CI 1.11-1.82; I2 = 0%; 3 studies; confirmed by TSA with high certainty, and the number needed to harm is 7). Higher protein delivery also significantly increased serum urea (mean difference 2.31 mmol/L, 95% CI 1.64-2.97; I2 = 0%; 7 studies). CONCLUSION Higher, compared with lower protein delivery, does not appear to affect clinical outcomes in general critically ill patients but may increase mortality rates in patients with AKI. Further investigation of the combined early physical rehabilitation intervention in non-AKI patients is warranted. PROSPERO ID CRD42023441059.
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Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité, Berlin, Germany.
| | - Ellen Dresen
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Charles Chin Han Lew
- Department of Dietetics and Nutrition, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Julia Bels
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, 6229HX, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Aileen Hill
- Department of Anesthesiology and Department Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu Province, China
| | - Arthur van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede & Wageningen University & Research, Wageningen, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, 6229HX, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité, Berlin, Germany
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
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14
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Lee ZY, Stoppe C, Hartl W, Elke G, Heyland DK, Lew CCH. Two half-truths don't make one truth: High protein intake does not improve mortality in the critically ill. Clin Nutr 2024; 43:18-19. [PMID: 37992634 DOI: 10.1016/j.clnu.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany.
| | - Christian Stoppe
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany; University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Wolfgang Hartl
- Department of General, Visceral, and Transplantation Surgery, University Medical Center, Campus Grosshadern, LMU Munich, Germany
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Charles Chin Han Lew
- Department of Dietetics and Nutrition, Ng Teng Fong General Hospital, Singapore 1 Jurong East Street 21, Singapore 609606, Singapore
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15
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Elke G, Hartl WH, Adolph M, Angstwurm M, Brunkhorst FM, Edel A, Heer GD, Felbinger TW, Goeters C, Hill A, Kreymann KG, Mayer K, Ockenga J, Petros S, Rümelin A, Schaller SJ, Schneider A, Stoppe C, Weimann A. [Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2023; 118:1-13. [PMID: 37067563 PMCID: PMC10106891 DOI: 10.1007/s00063-023-01001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 04/18/2023]
Abstract
This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.
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Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 Haus R3, 24105, Kiel, Deutschland.
| | - Wolfgang H Hartl
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Großhadern, München, Deutschland
| | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Matthias Angstwurm
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Innenstadt, München, Deutschland
| | - Frank M Brunkhorst
- Zentrum für Klinische Studien, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Deutschland
| | - Andreas Edel
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas W Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching und Neuperlach, Städtisches Klinikum München GmbH, München, Deutschland
| | - Christiane Goeters
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster, Deutschland
| | - Aileen Hill
- Kliniken für Anästhesiologie und Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland
| | | | - Konstantin Mayer
- Klinik für Pneumologie und Schlafmedizin, St. Vincentius-Kliniken, Karlsruhe, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte, Bremen, Deutschland
| | - Sirak Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Andreas Rümelin
- Anästhesie, Intensivmedizin und Notfallmedizin, Helios St. Elisabeth-Krankenhaus Bad Kissingen, Kissingen, Deutschland
| | - Stefan J Schaller
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Medizinische Fakultät, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
| | - Andrea Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Christian Stoppe
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Arved Weimann
- Abteilung für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Leipzig, Deutschland
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Stoppe C, Engelman DT. Cardiac Rehabilitation and Its Role in Enhanced Recovery After Surgery. Ann Thorac Surg 2023; 116:1105-1106. [PMID: 37517529 DOI: 10.1016/j.athoracsur.2023.07.018] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023]
Affiliation(s)
- Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center, Deutsches Herzzentrum der Charité, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany.
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Medical School Baystate, Springfield, Massachusetts
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17
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Stoppe C, Patel JJ, Zarbock A, Lee ZY, Rice TW, Mafrici B, Wehner R, Chan MHM, Lai PCK, MacEachern K, Myrianthefs P, Tsigou E, Ortiz-Reyes L, Jiang X, Day AG, Hasan MS, Meybohm P, Ke L, Heyland DK. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care 2023; 27:399. [PMID: 37853490 PMCID: PMC10585921 DOI: 10.1186/s13054-023-04663-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 08/08/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Based on low-quality evidence, current nutrition guidelines recommend the delivery of high-dose protein in critically ill patients. The EFFORT Protein trial showed that higher protein dose is not associated with improved outcomes, whereas the effects in critically ill patients who developed acute kidney injury (AKI) need further evaluation. The overall aim is to evaluate the effects of high-dose protein in critically ill patients who developed different stages of AKI. METHODS In this post hoc analysis of the EFFORT Protein trial, we investigated the effect of high versus usual protein dose (≥ 2.2 vs. ≤ 1.2 g/kg body weight/day) on time-to-discharge alive from the hospital (TTDA) and 60-day mortality and in different subgroups in critically ill patients with AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria within 7 days of ICU admission. The associations of protein dose with incidence and duration of kidney replacement therapy (KRT) were also investigated. RESULTS Of the 1329 randomized patients, 312 developed AKI and were included in this analysis (163 in the high and 149 in the usual protein dose group). High protein was associated with a slower time-to-discharge alive from the hospital (TTDA) (hazard ratio 0.5, 95% CI 0.4-0.8) and higher 60-day mortality (relative risk 1.4 (95% CI 1.1-1.8). Effect modification was not statistically significant for any subgroup, and no subgroups suggested a beneficial effect of higher protein, although the harmful effect of higher protein target appeared to disappear in patients who received kidney replacement therapy (KRT). Protein dose was not significantly associated with the incidence of AKI and KRT or duration of KRT. CONCLUSIONS In critically ill patients with AKI, high protein may be associated with worse outcomes in all AKI stages. Recommendation of higher protein dosing in AKI patients should be carefully re-evaluated to avoid potential harmful effects especially in patients who were not treated with KRT. TRIAL REGISTRATION This study is registered at ClinicalTrials.gov (NCT03160547) on May 17th 2017.
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Affiliation(s)
- Christian Stoppe
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany.
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alex Zarbock
- Department of Anaesthesiology and Intensive Care Medicine, University of Münster, Münster, Germany
| | - Zheng-Yii Lee
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bruno Mafrici
- Renal and Transplantation Unit, Department of Dietetics and Nutrition, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, UK
| | - Rebecca Wehner
- Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Kristen MacEachern
- Intensive Care Unit, Mount Sinai Hospital, Sinai Health System, Toronto, Canada
| | | | - Evdoxia Tsigou
- Intensive Care Unit, Agioi Anargiroi Hospital, Athens, Greece
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada.
- Department of Critical Care Medicine, Queen's University, Watkins 5, Kingston General Hospital, Kingston, ON, K7L 2V7, Canada.
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18
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Patel JJ, Lee ZY, Stoppe C, Heyland DK. EFFORT Protein trial: questions remain - Authors' reply. Lancet 2023; 402:964. [PMID: 37716768 DOI: 10.1016/s0140-6736(23)01253-9] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/16/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53225, USA.
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Würzburg, Würzburg, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit and Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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19
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Patel JJ, Rice TW, Mundi MS, Stoppe C, McClave SA. Nutrition dose in the early acute phase of critical illness: Finding the sweet spot and heeding the lessons from the NUTRIREA trials. JPEN J Parenter Enteral Nutr 2023; 47:859-865. [PMID: 37354044 DOI: 10.1002/jpen.2539] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 06/26/2023]
Abstract
The landmark NUTRIREA-2 and NUTRIREA-3 trials compared the route and dose of nutrition, respectively, in critically ill patients with circulatory shock. The results of both trials support a "less-is-more" paradigm shift in the early acute phase of critical illness. In this review, the authors outline and appraise the results of the NUTRIREA-2 and NUTRIREA-3 trials, introduce the concept of identifying the "sweet spot" for nutrition dose based on severity of illness/nutrition risk and nutrition dose, and identify the unintended consequences of delivering full-dose nutrition in sicker critically ill patients during the early acute phase of critical illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Wuerzberg, Germany
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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20
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Asare Y, Stoppe C, Bernhagen J. Tracing the failing heart: dual genetic fate mapping for target identification. Signal Transduct Target Ther 2023; 8:287. [PMID: 37537182 PMCID: PMC10400625 DOI: 10.1038/s41392-023-01564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/07/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Yaw Asare
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München (KUM), Ludwig-Maximilian-University (LMU), 81377, Munich, Germany
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, 97080, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Charité Berlin, 13353, Berlin, Germany
| | - Jürgen Bernhagen
- Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München (KUM), Ludwig-Maximilian-University (LMU), 81377, Munich, Germany.
- Munich Cluster for Systems Neurology, 81377, Munich, Germany.
- Munich Heart Alliance, 80802, Munich, Germany.
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21
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Ortiz-Reyes L, Lee ZY, Chin Han Lew C, Hill A, Jeschke MG, Turgeon AF, Cancio L, Stoppe C, Patel JJ, Day AG, Heyland DK. The Efficacy of Glutamine Supplementation in Severe Adult Burn Patients: A Systematic Review With Trial Sequential Meta-Analysis. Crit Care Med 2023; 51:1086-1095. [PMID: 37114912 DOI: 10.1097/ccm.0000000000005887] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/29/2023]
Abstract
OBJECTIVES Evidence supporting glutamine supplementation in severe adult burn patients has created a state of uncertainty due to the variability in the treatment effect reported across small and large randomized controlled trials (RCTs). We aimed to systematically review the effect of glutamine supplementation on mortality in severe adult burn patients. DATA SOURCES MEDLINE, Embase, CINAHL, and Cochrane Central were searched from inception to February 10, 2023. STUDY SELECTION RCTs evaluating the effect of enteral or IV glutamine supplementation alone in severe adult burn patients were included. DATA EXTRACTION Two reviewers independently extracted data on study characteristics, burn injury characteristics, description of the intervention between groups, adverse events, and clinical outcomes. DATA SYNTHESIS Random effects meta-analyses were performed to estimate the pooled risk ratio (RR). Trial sequential analyses (TSA) for mortality and infectious complications were performed. Ten RCTs (1,577 patients) were included. We observed no significant effect of glutamine supplementation on overall mortality (RR, 0.65, 95% CI, 0.33-1.28; p = 0.21), infectious complications (RR, 0.83; 95% CI, 0.63-1.09; p = 0.18), or other secondary outcomes. In subgroup analyses, we observed no significant effects based on administration route or burn severity. We did observe a significant subgroup effect between single and multicenter RCTs in which glutamine significantly reduced mortality and infectious complications in singe-center RCTs but not in multicenter RCTs. However, TSA showed that the pooled results of single-center RCTs were type 1 errors and further trials would be futile. CONCLUSIONS Glutamine supplementation, regardless of administration, does not appear to improve clinical outcomes in severely adult burned patients.
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Affiliation(s)
- Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Aileen Hill
- Department of Anesthesiology and Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Marc G Jeschke
- Department of Surgery, McMaster University, Hamilton, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Quebec-Universite Laval Research Center, Quebec City, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Universite Laval, Quebec City, QC, Canada
| | - Leopoldo Cancio
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX
| | - Christian Stoppe
- Department of Anesthesiology, Würzburg University, Würzburg, Germany
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin and Charite-Universitatsmedizin, Berlin, Germany
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Andrew G Day
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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22
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Mohsen G, Stroemer A, Mayr A, Kunsorg A, Stoppe C, Wittmann M, Velten M. Effects of Omega-3 Fatty Acids on Postoperative Inflammatory Response: A Systematic Review and Meta-Analysis. Nutrients 2023; 15:3414. [PMID: 37571352 PMCID: PMC10421202 DOI: 10.3390/nu15153414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 06/10/2023] [Revised: 07/26/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023] Open
Abstract
Initial evidence indicates that preoperatively initiated administration of omega-3 fatty acids (FAs) attenuates the postoperative inflammatory reaction. The effects of immunonutrition containing omega-3 FAs, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), on the inflammatory response to abdominal surgery continues to be unclear, although improved outcomes have been reported. Therefore, we determined the effectiveness of preoperatively initiated omega-3 FAs administration on postoperative inflammation defined as CRP (C-Reactive Protein), IL-6 (Interleukin 6), and WBC (White Blood Count) and potential effects on postoperative length of hospital stay (LOS) due to an improved inflammatory response. METHODS a literature search of Cochrane Library was conducted to identify all randomized controlled trials (RCTs) investigating the effects of preoperatively initiated omega-3 to standard care, placebo, or other immunonutrients excluding omega-3 FAs in patients undergoing abdominal surgery until the end of December 2022. RESULTS a total of 296 articles were found during the initial search. Thirteen RCTs involving 950 patients were identified that met the search criteria. These were successively analyzed and included in this meta-analysis. There was no significant difference between the groups with respect to inflammatory markers IL-6: -0.55 [-1.22; 0.12] p = 0.10, CRP: -0.14 [-0.67; 0.40] p = 0.55, WBC: -0.58 [-3.05; 1.89] p = 0.42, or hospital stay -0.5 [-1.43; 0.41] p = 0.2. CONCLUSION although reduced inflammatory markers were observed, preoperative administration of omega-3 FAs immunonutrients had no significant effect on the postoperative inflammatory response in patients undergoing abdominal surgeries. Yet, results obtained from this study are inconclusive, likely attributed to the limited number of trials and patients included. Further studies are required to obtain a better educated verdict.
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Affiliation(s)
- Ghaith Mohsen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (A.K.); (M.W.); (M.V.)
| | - Annika Stroemer
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany; (A.S.); (A.M.)
| | - Andreas Mayr
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany; (A.S.); (A.M.)
| | - Andrea Kunsorg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (A.K.); (M.W.); (M.V.)
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, 97080 Würzburg, Germany;
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Charité Berlin, 13353 Berlin, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (A.K.); (M.W.); (M.V.)
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (A.K.); (M.W.); (M.V.)
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23
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Lee ZY, Lew CCH, Berger MM, Hill A, Stoppe C. Nutrition during the acute phase of critical illness: discussions on NUTRIREA-3. Lancet Respir Med 2023; 11:e62-e63. [PMID: 37244261 DOI: 10.1016/s2213-2600(23)00214-x] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, 609606, Singapore; Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore.
| | - Mette M Berger
- Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland
| | - Aileen Hill
- Department of Anesthesiology and Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany; Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
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24
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Radke DI, Homayr AL, Stoppe C, Elke G. Vitamin C in critical illness: end of the story or still a place? Curr Opin Crit Care 2023:00075198-990000000-00092. [PMID: 37306524 DOI: 10.1097/mcc.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE OF REVIEW Critical illness is associated with decreased micronutrient levels, including vitamin C, an essential antioxidant for systemic inflammation. This review discusses the most recent evidence of high-dose vitamin C monotherapy in critically ill adults. RECENT FINDINGS Three randomized-controlled trials (RCTs) were published in 2022. A pilot study including 40 patients with septic shock could not detect significant differences in outcome parameters after administering vitamin C. A multicenter study with 124 septic patients showed no significant difference in 28-day mortality, while vitamin C was associated with an increased risk of acute kidney dysfunction. The LOVIT trial, an international prospective RCT in 872 septic patients, revealed an increased risk of the composite endpoint persistent organ dysfunction plus death at day 28 in the high-dose vitamin C group. Six systematic reviews and meta-analyses (SRMA), including up to 4740 patients published before and 2 SRMA publications including these RCTs showed divergent results on clinical endpoints including mortality. SUMMARY The use of high-dose intravenous vitamin C cannot be recommended for the septic critically ill in clinical practice since the LOVIT trial. Further research is needed to evaluate its potential role in other critically ill patients.
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Affiliation(s)
- David I Radke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Anna Lulu Homayr
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel
| | - Christian Stoppe
- Department of Anesthesiology & Intensive Care Medicine, University Hospital Würzburg
- Departments of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel
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25
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Ott S, Notz Q, Menger J, Stoppe C. [The Role of the Percutaneous Impella Pump in Anesthesia and Intensive Care]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:304-320. [PMID: 37192639 DOI: 10.1055/a-1859-0105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
The use of temporary mechanical circulatory support (tMCS) devices and in particular the increasing use of the Impella device family has gained significant interest over the last two decades. Nowadays, its use plays a well-established key role in both the treatment of cardiogenic shock, and as a preventive and protective therapeutic option during high-risk procedures in both cardiac surgery and cardiology, such as complex percutaneous interventions (protected PCI). Thus, it is not surprising that the Impella device is more and more present in the perioperative setting and especially in patients on intensive care units. Despite the numerous advantages such as cardiac resting and hemodynamic stabilization, potential adverse events exist, which may lead to severe, but preventable complications, so that adequate education, early recognition of such events and a subsequent adequate management are crucial in patients with tMCS. This article provides an overview especially for anesthesiologists and intensivists focusing on technical basics, indications and contraindications for its use with special focus on the intra- and postoperative management. Furthermore, troubleshooting for most common complications for patients on Impella support is provided.
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26
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Liakopoulos OJ, Kuhn EW, Hellmich M, Schlömicher M, Strauch J, Reents W, Diegeler A, Thielmann M, Wendt D, Börgermann J, Gummert JF, Stoppe C, Goetzenich A, Martens S, Reichenspurner H, Wippermann J, Reuter H, Choi YH, Wahlers T. Statin loading before coronary artery bypass grafting: a randomized trial. Eur Heart J 2023:7136604. [PMID: 37086268 DOI: 10.1093/eurheartj/ehad238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/01/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023] Open
Abstract
AIMS Evidence suggests that a high-dose statin loading before a percutaneous coronary revascularization improves outcomes in patients receiving long-term statins. This study aimed to analyse the effects of such an additional statin therapy before surgical revascularization. METHODS AND RESULTS This investigator-initiated, randomized, double-blind, and placebo-controlled trial was conducted from November 2012 to April 2019 at 14 centres in Germany. Adult patients (n = 2635) with a long-term statin treatment (≥30 days) who were scheduled for isolated coronary artery bypass grafting (CABG) were randomly assigned to receive a statin-loading therapy or placebo at 12 and 2 h prior to surgery using a web-based system. The primary outcome of major adverse cardiac and cerebrovascular events (MACCE) was a composite consisting of all-cause mortality, myocardial infarction (MI), and a cerebrovascular event occuring within 30 days after surgery. Key secondary endpoints included a composite of cardiac death and MI, myocardial injury, and death within 12 months. Non-statistically relevant differences were found in the modified intention-to-treat analysis (2406 patients; 1203 per group) between the statin (13.9%) and placebo groups (14.9%) for the primary outcome [odds ratio (OR) 0.93, 95% confidence interval (CI) 0.74-1.18; P = 0.562] or any of its individual components. Secondary endpoints including cardiac death and MI (12.1% vs. 13.5%; OR 0.88, 95% CI 0.69-1.12; P = 0.300), the area under the troponin T-release curve (median 0.398 vs. 0.394 ng/ml, P = 0.333), and death at 12 months (3.1% vs. 2.9%; P = 0.825) were comparable between treatment arms. CONCLUSION Additional statin loading before CABG failed to reduce the rate of MACCE occuring within 30 days of surgery.
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Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
- Department of Cardiac Surgery, Kerckhoff-Clinic, Campus Kerckhoff, Justus-Liebig-University of Giessen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, University Hospital Cologne, Cologne, Germany
| | - Markus Schlömicher
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Justus Strauch
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Wilko Reents
- Department of Cardiac Surgery, Bad Neustadt a. d. Saale, Germany
| | - Anno Diegeler
- Department of Cardiac Surgery, Bad Neustadt a. d. Saale, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
| | - Jochen Börgermann
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Jan F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Christian Stoppe
- Department of Thoracic and Cardiovascular Surgery, University Hospital Aachen, Aachen, Germany
| | - Andreas Goetzenich
- Department of Thoracic and Cardiovascular Surgery, University Hospital Aachen, Aachen, Germany
| | - Sven Martens
- Department of Cardiac and Thoracic Surgery, University Hospital Münster, Münster, Germany
| | | | - Jens Wippermann
- Department of Cardiothoracic Surgery, Otto-von Guericke University, Magdeburg, Germany
| | - Hannes Reuter
- Department of Cardiology, University Hospital Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
- Department of Cardiac Surgery, Kerckhoff-Clinic, Campus Kerckhoff, Justus-Liebig-University of Giessen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Dresen E, Notz Q, Menger J, Homayr AL, Lindner M, Radke DI, Stoppe C, Elke G. What the clinician needs to know about medical nutrition therapy in critically ill patients in 2023: A narrative review. Nutr Clin Pract 2023; 38:479-498. [PMID: 37021324 DOI: 10.1002/ncp.10984] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/15/2023] [Accepted: 02/26/2023] [Indexed: 04/07/2023] Open
Abstract
Medical nutrition therapy (MNT) represents an essential element in the medical care of critically ill patients admitted to an intensive care unit (ICU). Increasing awareness exists that energy and nutrients not only preserve body structures such as lean body/muscle mass but also represent promising therapeutic elements to target the profound metabolic, inflammatory, endocrinologic, and immunologic alterations occurring during critical illness. However, despite intense research activities for years, diverse aspects of MNT such as the optimal timing, dosing, and composition of energy and macronutrient supply, as well as the role of micronutrients, are still an issue of debate resulting from strong heterogeneity in methods and findings of respective studies. These discrepancies are also reflected in diverging recommendations of international clinical nutrition guidelines for specific topics. In addition, implementing targeted, personalized MNT strategies in routine clinical practice underlies difficulties and challenges resulting from disease-specific issues and/or organizational, structural, and educational aspects. This narrative review aims to summarize the most recent evidence relevant to clinical practice on selected aspects of MNT in adult patients in the ICU and to provide guidance for implementing evidence-based approaches for adequate energy and nutrient supply in the ICU setting.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Quirin Notz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johannes Menger
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Anna L Homayr
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David I Radke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Stoppe C, Dresen E, Wendt S, Elke G, Patel JJ, McKeever L, Chourdakis M, McDonald B, Meybohm P, Lindner M, Arora RC, O Brien B, von Dossow V, Efremov S, Lomivorotov V, Compher C, Yaung J, Imai T, Nurok M, Ho A, von Loeffelholz C, Hing FP, Jiang X, Heyland DK. Current practices in medical nutrition therapy in the cardiac surgical critical care setting - an international multicenter observational study. JPEN J Parenter Enteral Nutr 2023. [PMID: 36912124 DOI: 10.1002/jpen.2495] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 10/17/2022] [Revised: 01/19/2023] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Cardiac surgery patients with prolonged stay in the intensive care unit (ICU) are at high-risk for acquired malnutrition. Medical nutrition therapy practices in cardiac surgery patients are unknown. The objective of this study is to describe current nutrition practices in critically ill cardiac surgery patients worldwide. METHODS We conducted a prospective observational study in 13 international ICUs involving mechanically ventilated cardiac surgery patients with an ICU stay of at least 72 hours. Collected data included calorie and protein prescription, type and time to initiation of nutrition, and actual quantity of energy and protein delivered (maximum: 12 days). RESULTS Among 237 enrolled patients, enteral nutrition (EN) was started, on average, 45 hours after ICU admission (range 0-277 hours; site average 53 [range 10-79 hours]). EN was prescribed in 187 (79%) patients and combined EN and parenteral nutrition (PN) in 33 (14%). Overall, patients received 44.2% (0.0-117.2%) of prescribed calories and 39.7% (0.0-122.8%) of prescribed protein. At a site level, the average nutritional adequacy was 47.5% (30.5-78.6%) for calories and 43.6% (21.7-76.6%) for protein received from all nutritional sources. CONCLUSION Critically ill cardiac surgery patients with prolonged ICU stay experience significant delays in starting EN and receive low levels of calories and protein. There exists tremendous variability in site performance, whereas achieving optimal nutrition performance is doable. VIDEO ABSTRACT A video abstract (Video S1) is provided with the supplementary materials. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Germany
| | - Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Germany
| | - Sebastian Wendt
- Department of Intensive Care Medicine, University Hospital, RWTH Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liam McKeever
- Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois, USA
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki (AUTH), Thessaloniki, Greece
| | - Bernard McDonald
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ben O Brien
- Departments of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin and Charité - Universitätsmedizin, Berlin, Germany
| | - Vera von Dossow
- Institute of Anesthesiology, Heart and Diabetes Centre North Rhine Westphalia, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Sergey Efremov
- Department of Anesthesiology and Intensive Care, Saint Petersburg State University Hospital, St. Petersburg, Russian Federation
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Novosibirsk State University, Novosibirsk, Russian Federation
| | - Charlene Compher
- School of Nursing, University of Pennsylvania, Philadelphia, and Hospital of the University of Pennsylvania, PA, USA
| | - Jill Yaung
- Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Taryne Imai
- Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Nurok
- Departments of Anesthesiology and Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrea Ho
- Departments of Cardiac Surgery and Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Foong Pui Hing
- Dietetics & Food Services, National Heart Institute, Kuala Lumpur, Malaysia
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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Lee ZY, Ortiz-Reyes L, Lew CCH, Hasan MS, Ke L, Patel JJ, Stoppe C, Heyland DK. Intravenous vitamin C monotherapy in critically ill patients: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Ann Intensive Care 2023; 13:14. [PMID: 36882644 PMCID: PMC9990974 DOI: 10.1186/s13613-023-01116-x] [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: 01/11/2023] [Accepted: 02/26/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND A recent landmark randomized controlled trial (RCT) in septic patients demonstrated an increased risk of death and persistent organ dysfunction with intravenous Vitamin C (IVVC) monotherapy, which represents a disparate result from previous systematic reviews and meta-analyses (SRMA). We performed an updated SRMA of IVVC monotherapy to summarize and explore heterogeneity across current trials and conduct trial sequential analysis (TSA) to guard against type-I or type-II statistical errors. METHODS RCTs evaluating IVVC in adult critically ill patients were included. Four databases were searched from inception to 22 June 2022 without language restrictions. The primary outcome was overall mortality. Random effect meta-analysis was performed to estimate the pooled risk ratio. TSA for mortality was performed using the DerSimonian-Laird random effect model, alpha 5%, beta 10%, and relative risk reduction (RRR) of 30%, 25%, and 20%. RESULTS We included 16 RCTs (n = 2130). IVVC monotherapy is associated with significant reduction in overall mortality [risk ratio (RR) 0.73, 95% confidence interval (CI) 0.60-0.89; p = 0.002; I2 = 42%]. This finding is supported by TSA using RRR of 30% and 25%, and sensitivity analysis using fixed-effect meta-analysis. However, the certainty of our mortality finding was rated low using GRADE due to the serious risk of bias and inconsistency. In a priori subgroup analyses, we found no differences between single vs multicenter, higher (≥ 10,000 mg/day) vs lower dose and sepsis vs non-sepsis trials. Post-hoc, we found no differences in subgroup analysis of earlier (< 24 h) vs delayed treatment, longer (> 4 days) vs shorter treatment duration, and low vs other risk of bias studies. IVVC may have the greatest benefit in trials that enrolled patients above (i.e., > 37.5%; RR 0.65, 95% CI 0.54-0.79) vs below (i.e., ≤ 37.5%; RR 0.89, 95% CI 0.68-1.16) median control group mortality (test for subgroup differences: p = 0.06), and TSA supported this. CONCLUSIONS IVVC monotherapy may be associated with mortality benefits in critically ill patients, particularly in patients with a high risk of dying. Given the low certainty of evidence, this potentially life-saving therapy warrants further studies to identify the optimal timing, dosage, treatment duration, and patient population that will benefit most from IVVC monotherapy. PROSPERO Registration ID: CRD42022323880. Registered 7th May 2022.
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Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, No. 305 Zhongshan East Road, Nanjing, 210000, Jiangsu, China.,National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
| | - Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, K7L 3N6, Canada.
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30
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Hill A, Starchl C, Dresen E, Stoppe C, Amrein K. [Vitamin C and D supplementation in critically ill patients]. Med Klin Intensivmed Notfmed 2023; 118:114-121. [PMID: 36629872 PMCID: PMC9838489 DOI: 10.1007/s00063-022-00986-6] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023]
Abstract
Micronutrient supplementation as part of the medical nutrition therapy for critically ill patients has received much attention in the past few years. Nevertheless, in clinical practice uncertainty remains about the optimal supplementation strategy, including which substance at which dosage should be administered at what time to specific groups of patients. Thus, the aim of this narrative review is to summarize the current evidence and recommendations for the micronutrients vitamin C and vitamin D. The physiological and pathophysiological roles of both vitamins are presented, recently published clinical trials are discussed, and the recommendations of the current guidelines are summarized. In addition, pragmatic tips for use in everyday clinical practice in the intensive care unit are given.
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Affiliation(s)
- Aileen Hill
- Klinik für Anästhesiologie, Uniklinik RWTH Aachen, Aachen, Deutschland.
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland.
| | - Christina Starchl
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität zu Graz, Graz, Österreich
| | - Ellen Dresen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Uniklinik Würzburg, Würzburg, Deutschland
| | - Christian Stoppe
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Uniklinik Würzburg, Würzburg, Deutschland
| | - Karin Amrein
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität zu Graz, Graz, Österreich.
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31
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Beck I, Tapking C, Haug V, Nolte S, Böcker A, Stoppe C, Kneser U, Hirche C, Hundeshagen G. Short- and long term hyposmia, hypogeusia, dysphagia and dysphonia after facial burn injury - A prospective matched cohort study. Burns 2023; 49:380-387. [PMID: 35525769 DOI: 10.1016/j.burns.2022.04.008] [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: 11/22/2021] [Revised: 03/03/2022] [Accepted: 04/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Facial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns. METHODS In a prospective observational controlled study, we evaluated hyposmia via the Sniffin' Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments. RESULTS Fifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia. CONCLUSION Hyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.
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Affiliation(s)
- Inessa Beck
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, Ulm, Germany
| | - Arne Böcker
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery, Hand Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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Stoppe C, McDonald B, Meybohm P, Christopher KB, Fremes S, Whitlock R, Mohammadi S, Kalavrouziotis D, Elke G, Rossaint R, Helmer P, Zacharowski K, Günther U, Parotto M, Niemann B, Böning A, Mazer CD, Jones PM, Ferner M, Lamarche Y, Lamontagne F, Liakopoulos OJ, Cameron M, Müller M, Zarbock A, Wittmann M, Goetzenich A, Kilger E, Schomburg L, Day AG, Heyland DK. Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients: The SUSTAIN CSX Randomized Clinical Trial. JAMA Surg 2023; 158:235-244. [PMID: 36630120 PMCID: PMC9857635 DOI: 10.1001/jamasurg.2022.6855] [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: 01/12/2023]
Abstract
Importance Selenium contributes to antioxidative, anti-inflammatory, and immunomodulatory pathways, which may improve outcomes in patients at high risk of organ dysfunctions after cardiac surgery. Objective To assess the ability of high-dose intravenous sodium selenite treatment to reduce postoperative organ dysfunction and mortality in cardiac surgery patients. Design, Setting, and Participants This multicenter, randomized, double-blind, placebo-controlled trial took place at 23 sites in Germany and Canada from January 2015 to January 2021. Adult cardiac surgery patients with a European System for Cardiac Operative Risk Evaluation II score-predicted mortality of 5% or more or planned combined surgical procedures were randomized. Interventions Patients were randomly assigned (1:1) by a web-based system to receive either perioperative intravenous high-dose selenium supplementation of 2000 μg/L of sodium selenite prior to cardiopulmonary bypass, 2000 μg/L immediately postoperatively, and 1000 μg/L each day in intensive care for a maximum of 10 days or placebo. Main Outcomes and Measures The primary end point was a composite of the numbers of days alive and free from organ dysfunction during the first 30 days following cardiac surgery. Results A total of 1416 adult cardiac surgery patients were analyzed (mean [SD] age, 68.2 [10.4] years; 1043 [74.8%] male). The median (IQR) predicted 30-day mortality by European System for Cardiac Operative Risk Evaluation II score was 8.7% (5.6%-14.9%), and most patients had combined coronary revascularization and valvular procedures. Selenium did not increase the number of persistent organ dysfunction-free and alive days over the first 30 postoperative days (median [IQR], 29 [28-30] vs 29 [28-30]; P = .45). The 30-day mortality rates were 4.2% in the selenium and 5.0% in the placebo group (odds ratio, 0.82; 95% CI, 0.50-1.36; P = .44). Safety outcomes did not differ between the groups. Conclusions and Relevance In high-risk cardiac surgery patients, perioperative administration of high-dose intravenous sodium selenite did not reduce morbidity or mortality. The present data do not support the routine perioperative use of selenium for patients undergoing cardiac surgery. Trial Registration ClinicalTrials.gov Identifier: NCT02002247.
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Affiliation(s)
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | | | | | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Gunnar Elke
- University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Philipp Helmer
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | | | - Ulf Günther
- Oldenburg Clinic, University of Oldenburg, Oldenburg, Germany
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada.,Division of Critical Care Medicine, Department of Anesthesia and Interdepartmental University of Toronto, Toronto, Ontario, Canada
| | | | | | - C David Mazer
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | | | - Marion Ferner
- University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Yoan Lamarche
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Oliver J Liakopoulos
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | | | - Matthias Müller
- University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | | | | | - Andreas Goetzenich
- University Hospital Aachen, Aachen, Germany.,now with Abiomed Europe GmbH, Aachen, Germany
| | - Erich Kilger
- Ludwig Maximilian University of Munich, Munich, Germany
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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33
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Heyland DK, Patel J, Compher C, Rice TW, Bear DE, Lee ZY, González VC, O'Reilly K, Regala R, Wedemire C, Ibarra-Estrada M, Stoppe C, Ortiz-Reyes L, Jiang X, Day AG. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet 2023; 401:568-576. [PMID: 36708732 DOI: 10.1016/s0140-6736(22)02469-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND On the basis of low-quality evidence, international critical care nutrition guidelines recommend a wide range of protein doses. The effect of delivering high-dose protein during critical illness is unknown. We aimed to test the hypothesis that a higher dose of protein provided to critically ill patients would improve their clinical outcomes. METHODS This international, investigator-initiated, pragmatic, registry-based, single-blinded, randomised trial was undertaken in 85 intensive care units (ICUs) across 16 countries. We enrolled nutritionally high-risk adults (≥18 years) undergoing mechanical ventilation to compare prescribing high-dose protein (≥2·2 g/kg per day) with usual dose protein (≤1·2 g/kg per day) started within 96 h of ICU admission and continued for up to 28 days or death or transition to oral feeding. Participants were randomly allocated (1:1) to high-dose protein or usual dose protein, stratified by site. As site personnel were involved in both prescribing and delivering protein dose, it was not possible to blind clinicians, but patients were not made aware of the treatment assignment. The primary efficacy outcome was time-to-discharge-alive from hospital up to 60 days after ICU admission and the secondary outcome was 60-day morality. Patients were analysed in the group to which they were randomly assigned regardless of study compliance, although patients who dropped out of the study before receiving the study intervention were excluded. This study is registered with ClinicalTrials.gov, NCT03160547. FINDINGS Between Jan 17, 2018, and Dec 3, 2021, 1329 patients were randomised and 1301 (97·9%) were included in the analysis (645 in the high-dose protein group and 656 in usual dose group). By 60 days after randomisation, the cumulative incidence of alive hospital discharge was 46·1% (95 CI 42·0%-50·1%) in the high-dose compared with 50·2% (46·0%-54·3%) in the usual dose protein group (hazard ratio 0·91, 95% CI 0·77-1·07; p=0·27). The 60-day mortality rate was 34·6% (222 of 642) in the high dose protein group compared with 32·1% (208 of 648) in the usual dose protein group (relative risk 1·08, 95% CI 0·92-1·26). There appeared to be a subgroup effect with higher protein provision being particularly harmful in patients with acute kidney injury and higher organ failure scores at baseline. INTERPRETATION Delivery of higher doses of protein to mechanically ventilated critically ill patients did not improve the time-to-discharge-alive from hospital and might have worsened outcomes for patients with acute kidney injury and high organ failure scores. FUNDING None.
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Affiliation(s)
- Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Department of Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Victoria C González
- Unidad de Soporte Metabólico y Nutricional Sanatorio Allende, Córdoba, Argentina
| | - Kevin O'Reilly
- King's College Hospital NHS Foundation Trust, London, UK
| | - Racquel Regala
- Clinical Nutrition, Legacy Salmon Creek Medical Center, Vancouver, WA, USA
| | - Courtney Wedemire
- Department of Food and Nutrition, Abbotsford Regional Hospital, Abbotsford, BC, Canada
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva Hospital Civil Fray Antonio Alcalde Universidad de Guadalajara, Jalisco, México
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
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Dresen E, Pimiento JM, Patel JJ, Heyland DK, Rice TW, Stoppe C. Overview of oxidative stress and the role of micronutrients in critical illness. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S38-S49. [PMID: 36468328 DOI: 10.1002/jpen.2421] [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: 04/04/2022] [Revised: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 12/12/2022]
Abstract
Inflammation and oxidative stress represent physiological response mechanisms to different types of stimuli and injury during critical illness. Its proper regulation is fundamental to cellular and organismal survival and are paramount to outcomes and recovery from critical illness. A proper maintenance of the delicate balance between inflammation, oxidative stress, and immune response is crucial for resolution from critical illness with important implications for patient outcome. The extent of inflammation and oxidative stress under normal conditions is limited by the antioxidant defense system of the human body, whereas the antioxidant capacity is commonly significantly compromised, and serum levels of micronutrients and vitamins significantly depleted in patients who are critically ill. Hence, the provision of antioxidants and anti-inflammatory nutrients may help to reduce the extent of oxidative stress and therefore improve clinical outcomes in patients who are critically ill. As existing evidence of the beneficial effects of antioxidant supplementation in patients who are critically ill is still unclear, actual findings about the most promising anti-inflammatory and antioxidative candidates selenium, vitamin C, zinc, and vitamin D will be discussed in this narrative review. The existing evidence provided so far demonstrates that several factors need to be considered to determine the efficacy of an antioxidant supplementation strategy in patients who are critically ill and indicates the need for adequately designed multicenter prospective randomized control trials to evaluate the clinical significance of different types and doses of micronutrients and vitamins in selected groups of patients with different types of critical illness.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Pimiento JM, Rice TW, Heyland DK, Stoppe C, Katz J, Morrison C, Mechanick JI, Patel JJ. Case presentation and panel discussion: Micronutrient therapy in critical illness. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S50-S53. [PMID: 36468248 DOI: 10.1002/jpen.2436] [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: 05/15/2022] [Revised: 07/23/2022] [Accepted: 08/02/2022] [Indexed: 12/07/2022]
Abstract
Over the past decade, the use of supraphysiologic doses of micronutrients (also called metabolic resuscitation) in critically ill patients has gained significant attention. Building upon preclinical and observational human data, numerous randomized controlled trials have tested the impact of multiple micronutrients on various outcomes in critically ill patients. At the 2022 American Society for Parenteral and Enteral Nutrition Preconference Course, three world-renowned speakers delivered talks on the (1) overall role of micronutrients and, specifically, (2) selenium and vitamin C and (3) vitamin D and zinc in critically ill patients. Here, the case presentation and discussion from the postsession question and answer period are presented. The moderator for this session was Jose Pimiento, MD, and the speakers and panelists were Christian Stoppe, MD, Todd Rice, MD, and Daren Heyland, MD.
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Affiliation(s)
- Jose M Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jennifer Katz
- Department of Surgery, Central Michigan University School of Medicine, Saginaw, Michigan, USA
| | - Chet Morrison
- Division of Gastroenterology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Jeffrey I Mechanick
- Division of Endocrinology, Diabetes, and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Dresen E, Naidoo O, Hill A, Elke G, Lindner M, Jonckheer J, De Waele E, Meybohm P, Modir R, Patel JJ, Christopher KB, Stoppe C. Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice. JPEN J Parenter Enteral Nutr 2023; 47:220-235. [PMID: 36495215 DOI: 10.1002/jpen.2467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Omy Naidoo
- Newtricion Wellness Dieticians, PMB Healthcare Centre, Pietermaritzburg, South Africa
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joop Jonckheer
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Vrije Universiteit Brussel, Brussels Health Campus, Jette, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth B Christopher
- Renal Division, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
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Dresen E, Lee ZY, Hill A, Notz Q, Patel JJ, Stoppe C. History of scurvy and use of vitamin C in critical illness: A narrative review. Nutr Clin Pract 2023; 38:46-54. [PMID: 36156315 DOI: 10.1002/ncp.10914] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 07/01/2022] [Revised: 08/01/2022] [Accepted: 08/28/2022] [Indexed: 01/11/2023] Open
Abstract
In 1747, an important milestone in the history of clinical research was set, as the Scottish surgeon James Lind conducted the first randomized controlled trial. Lind was interested in scurvy, a severe vitamin C deficiency which caused the death of thousands of British seamen. He found that a dietary intervention with oranges and lemons, which are rich in vitamin C by nature, was effective to recover from scurvy. Because of its antioxidative properties and involvement in many biochemical processes, the essential micronutrient vitamin C plays a key role in the human biology. Moreover, the use of vitamin C in critical illness-a condition also resulting in death of thousands in the 21st century-has gained increasing interest, as it may restore vascular responsiveness to vasoactive agents, ameliorate microcirculatory blood flow, preserve endothelial barriers, augment bacterial defense, and prevent apoptosis. Because of its redox potential and powerful antioxidant capacity, vitamin C represents an inexpensive and safe antioxidant, with the potential to modify the inflammatory cascade and improve clinical outcomes of critically ill patients. This narrative review aims to update and provide an overview on the role of vitamin C in the human biology and in critically ill patients, and to summarize current evidence on the use of vitamin C in diverse populations of critically ill patients, in specific focusing on patients with sepsis and coronavirus disease 2019.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Quirin Notz
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Hill A, Bergmann D, Schulte J, Zayat R, Marx G, Simon TP, Mossanen J, Brücken A, Stoppe C. Proenkephalin A and bioactive adrenomedullin are useful for risk prognostication in cardiac surgery. Front Cardiovasc Med 2023; 9:1017867. [PMID: 36756642 PMCID: PMC9900105 DOI: 10.3389/fcvm.2022.1017867] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/28/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Various clinical scores have been developed to predict organ dysfunction and mortality in patients undergoing cardiac surgery, but outcome prediction may be inaccurate for some patient groups. Proenkephalin A (penKid) and bioactive adrenomedullin (bio-ADM) have emerged as promising biomarkers correlating with shock and organ dysfunction. This imposes the question of whether they can be used as prognostic biomarkers for risk stratification in the perioperative setting of cardiac surgery. Methods Patients undergoing cardiac surgery were prospectively enrolled in this observational study. PenKid and bio-ADM plasma levels, as well as markers evaluating inflammation and organ dysfunction, were measured at five perioperative time points from before the induction of anesthesia to up to 48 h postoperatively. Clinical data regarding organ dysfunction and patient outcomes were recorded during the intensive care unit (ICU)-stay with a special focus on acute kidney injury (AKI). Results In 136 patients undergoing cardiac surgery, the bio-ADM levels increased and the penKid levels decreased significantly over time. PenKid was associated with chronic kidney disease (CKD), the incidence of AKI, and renal replacement therapy (RRT). Bio-ADM was associated with lactate and the need for vasopressors. PenKid was useful to predict an ICU-length of stay (LOS)>1 day and added prognostic value to the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE) II when measured after the end of cardiopulmonary bypass and 24 h after cardiac surgery. For bio-ADM, the same was true when measured 24 h after surgery. PenKid also added prognostic value to the EuroSCORE II for the combined outcome "ICU length of stay >1 day and in-hospital mortality." Conclusion The combination of preoperative EuroSCORE II and intraoperative measurement of penKid may be more useful to predict a prolonged ICU LOS and increased mortality than EuroSCORE II alone. Bio-ADM correlates with markers of shock. More research is encouraged for early risk stratification and validation of penKid and bio-ADM as a tool involved in clinical decisions, which may enable the early initiation of organ protective strategies.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, Medical Faculty RWTH Aachen, Aachen, Germany
| | | | | | - Rashad Zayat
- Department of Cardiothoracic Surgery, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Jana Mossanen
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Anne Brücken
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
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Neumaier F, Stoppe C, Stoykova A, Weiss M, Veldeman M, Höllig A, Hamou HA, Temel Y, Conzen C, Schmidt TP, Dogan R, Wiesmann M, Clusmann H, Schubert GA, Haeren RHL, Albanna W. Elevated concentrations of macrophage migration inhibitory factor in serum and cerebral microdialysate are associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Front Neurol 2023; 13:1066724. [PMID: 36712451 PMCID: PMC9880331 DOI: 10.3389/fneur.2022.1066724] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Objective Inflammation is increasingly recognized to be involved in the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH) and may increase the susceptibility to delayed cerebral ischemia (DCI). Macrophage migration inhibitory factor (MIF) has been shown to be elevated in serum and cerebrospinal fluid (CSF) after aSAH. Here, we determined MIF levels in serum, CSF and cerebral microdialysate (MD) at different time-points after aSAH and evaluated their clinical implications. Methods MIF levels were measured in serum, CSF and MD obtained from 30 aSAH patients during early (EPd1-4), critical (CPd5-15) and late (LPd16-21) phase after hemorrhage. For subgroup analyses, patients were stratified based on demographic and clinical data. Results MIF levels in serum increased during CPd5-15 and decreased again during LPd16-21, while CSF levels showed little changes over time. MD levels peaked during EPd1-4, decreased during CPd5-15 and increased again during LPd16-21. Subgroup analyses revealed significantly higher serum levels in patients with aneurysms located in the anterior vs. posterior circulation during CPd5-15 (17.3 [15.1-21.1] vs. 10.0 [8.4-11.5] ng/ml, p = 0.009) and in patients with DCI vs. no DCI during CPd5-15 (17.9 [15.1-22.7] vs. 11.9 [8.9-15.9] ng/ml, p = 0.026) and LPd16-21 (17.4 [11.7-27.9] vs. 11.3 [9.2-12.2] ng/ml, p = 0.021). In addition, MIF levels in MD during CPd5-15 were significantly higher in patients with DCI vs. no DCI (3.6 [1.8-10.7] vs. 0.2 [0.1-0.7] ng/ml, p = 0.026), while CSF levels during the whole observation period were similar in all subgroups. Conclusion Our findings in a small cohort of aSAH patients provide preliminary data on systemic, global cerebral and local cerebral MIF levels after aSAH and their clinical implications. Clinical trial registration ClinicalTrials.gov, identifier: NCT02142166.
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Affiliation(s)
- Felix Neumaier
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany,Institute of Radiochemistry and Experimental Molecular Imaging, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany,Institute of Neuroscience and Medicine, Nuclear Chemistry (INM-5), Forschungszentrum Jülich GmbH, Jülich, Germany
| | - Christian Stoppe
- Departments of Cardiac Anesthesiology and Intensive Care Medicine Charité, Berlin, Germany,Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany,Department of Anesthesiology and Intensive Care Medicine, Würzburg University, Würzburg, Germany
| | - Anzhela Stoykova
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany,Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Hussam Aldin Hamou
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | | | - Rabia Dogan
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany,Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany,*Correspondence: Walid Albanna ✉
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Hill A, Starchl C, Dresen E, Stoppe C, Amrein K. An update of the effects of vitamins D and C in critical illness. Front Med (Lausanne) 2023; 9:1083760. [PMID: 36726354 PMCID: PMC9885715 DOI: 10.3389/fmed.2022.1083760] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Many critically ill patients are vitamin D and vitamin C deficient and the current international guidelines state that hypovitaminoses should be compensated. However, uncertainty about optimal dosage, timing and indication exists in clinical routine, mainly due to the conflicting evidence. This narrative review discusses both micronutrients with regards to pathophysiology, clinical evidence of benefits, potential risks, and guideline recommendations. Evidence generated from the most recent clinical trials are summarized and discussed. In addition, pragmatic tips for the application of these vitamins in the clinical routine are given. The supplementations of vitamin D and C represent cost-effective and simple interventions with excellent safety profiles. Regarding vitamin D, critically ill individuals require a loading dose to improve 25(OH)D levels within a few days, followed by a daily or weekly maintenance dose, usually higher doses than healthy individuals are needed. For vitamin C, dosages of 100-200 mg/d are recommended for patients receiving parenteral nutrition, but needs may be as high as 2-3 g/d in acutely ill patients.
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Affiliation(s)
- Aileen Hill
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany,Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany,*Correspondence: Aileen Hill,
| | - Christina Starchl
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität Graz, Graz, Austria
| | - Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency, and Pain Medicine, University Hospital Würzburg, Würzburg, Germany,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Amrein
- Klinische Abteilung für Endokrinologie und Diabetologie, Klinik für Innere Medizin, Medizinische Universität Graz, Graz, Austria,Karin Amrein,
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Notz Q, Herrmann J, Schlesinger T, Kranke P, Sitter M, Helmer P, Stumpner J, Roeder D, Amrein K, Stoppe C, Lotz C, Meybohm P. Vitamin D deficiency in critically ill COVID-19 ARDS patients. Clin Nutr 2022; 41:3089-3095. [PMID: 33745749 PMCID: PMC7937427 DOI: 10.1016/j.clnu.2021.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 12/15/2020] [Revised: 02/16/2021] [Accepted: 03/01/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Vitamin D's pleiotropic effects include immune modulation, and its supplementation has been shown to prevent respiratory tract infections. The effectivity of vitamin D as a therapeutic intervention in critical illness remains less defined. The current study analyzed clinical and immunologic effects of vitamin D levels in patients suffering from coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome (ARDS). METHODS This was a single-center retrospective study in patients receiving intensive care with a confirmed SARS-CoV-2 infection and COVID-19 ARDS. 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum levels, pro- and anti-inflammatory cytokines and immune cell subsets were measured on admission as well as after 10-15 days. Clinical parameters were extracted from the patient data management system. Standard operating procedures included the daily administration of vitamin D3 via enteral feeding. RESULTS A total of 39 patients with COVID-19 ARDS were eligible, of which 26 were included in this study as data on vitamin D status was available. 96% suffered from severe COVID-19 ARDS. All patients without prior vitamin D supplementation (n = 22) had deficient serum levels of 25-hydroxyvitamin D. Vitamin D supplementation resulted in higher serum levels of 25-hydroxyvitamin D but not did not increase 1,25-dihydroxyvitamin D levels after 10-15 days. Clinical parameters did not differ between patients with sufficient or deficient levels of 25-hydroxyvitamin D. Only circulating plasmablasts were higher in patients with 25-hydroxyvitamin D levels ≥30 ng/ml (p = 0.029). Patients with 1,25-dihydroxyvitamin D levels below 20 pg/ml required longer mechanical ventilation (p = 0.045) and had a worse acute physiology and chronic health evaluation (APACHE) II score (p = 0.048). CONCLUSION The vast majority of COVID-19 ARDS patients had vitamin D deficiency. 25-hydroxyvitamin D status was not related to changes in clinical course, whereas low levels of 1,25-dihydroxyvitamin D were associated with prolonged mechanical ventilation and a worse APACHE II score.
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Affiliation(s)
- Quirin Notz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany,Corresponding author. Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany. Fax: +49 0 931 201 30019
| | - Johannes Herrmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Peter Kranke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Magdalena Sitter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Philipp Helmer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Jan Stumpner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Daniel Roeder
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Austria
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Christopher Lotz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Wuerzburg, Germany
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Stoppe C, Preiser JC, de Backer D, Elke G. Intravenous vitamin C in adults with sepsis in the intensive care unit: still LOV’IT? Crit Care 2022; 26:230. [PMID: 35908003 PMCID: PMC9339181 DOI: 10.1186/s13054-022-04106-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
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Heyland DK, Wibbenmeyer L, Pollack J, Friedman B, Turgeon AF, Eshraghi N, Jeschke MG, Bélisle S, Grau D, Mandell S, Velamuri SR, Hundeshagen G, Moiemen N, Shokrollahi K, Foster K, Huss F, Collins D, Savetamal A, Gurney JM, Depetris N, Stoppe C, Ortiz-Reyes L, Garrel D, Day AG. A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. N Engl J Med 2022; 387:1001-1010. [PMID: 36082909 DOI: 10.1056/nejmoa2203364] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation. METHODS In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk. RESULTS A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed. CONCLUSIONS In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).
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Affiliation(s)
- Daren K Heyland
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Lucy Wibbenmeyer
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jonathan Pollack
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Bruce Friedman
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alexis F Turgeon
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Niknam Eshraghi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Marc G Jeschke
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sylvain Bélisle
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Daisy Grau
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Samuel Mandell
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sai R Velamuri
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Gabriel Hundeshagen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Naiem Moiemen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kayvan Shokrollahi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kevin Foster
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Fredrik Huss
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Declan Collins
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alisa Savetamal
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jennifer M Gurney
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Nadia Depetris
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Christian Stoppe
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Luis Ortiz-Reyes
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Dominique Garrel
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Andrew G Day
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
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Berger MM, Burgos R, Casaer MP, De Robertis E, Delgado JCL, Fraipont V, Gonçalves-Pereira J, Pichard C, Stoppe C. Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients? Crit Care 2022; 26:271. [PMID: 36088342 PMCID: PMC9464377 DOI: 10.1186/s13054-022-04157-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
A multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.
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Menger J, Lee ZY, Notz Q, Wallqvist J, Hasan MS, Elke G, Dworschak M, Meybohm P, Heyland DK, Stoppe C. Administration of vitamin D and its metabolites in critically ill adult patients: an updated systematic review with meta-analysis of randomized controlled trials. Crit Care 2022; 26:268. [PMID: 36068584 PMCID: PMC9446655 DOI: 10.1186/s13054-022-04139-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background The clinical significance of vitamin D administration in critically ill patients remains inconclusive. The purpose of this systematic review with meta-analysis was to investigate the effect of vitamin D and its metabolites on major clinical outcomes in critically ill patients, including a subgroup analysis based on vitamin D status and route of vitamin D administration.
Methods Major databases were searched through February 9, 2022. Randomized controlled trials of adult critically ill patients with an intervention group receiving vitamin D or its metabolites were included. Random-effect meta-analyses were performed to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Risk of bias assessment included the Cochrane tool for assessing risk of bias in randomized trials. Results Sixteen randomized clinical trials with 2449 patients were included. Vitamin D administration was associated with lower overall mortality (16 studies: risk ratio 0.78, 95% confidence interval 0.62–0.97, p = 0.03; I2 = 30%), reduced intensive care unit length of stay (12 studies: mean difference − 3.13 days, 95% CI − 5.36 to − 0.89, n = 1250, p = 0.006; I2 = 70%), and shorter duration of mechanical ventilation (9 studies: mean difference − 5.07 days, 95% CI − 7.42 to − 2.73, n = 572, p < 0.0001; I2 = 54%). Parenteral administration was associated with a greater effect on overall mortality than enteral administration (test of subgroup differences, p = 0.04), whereas studies of parenteral subgroups had lower quality. There were no subgroup differences based on baseline vitamin D levels. Conclusions Vitamin D supplementation in critically ill patients may reduce mortality. Parenteral administration might be associated with a greater impact on mortality. Heterogeneity and assessed certainty among the studies limits the generalizability of the results. Trial registration: PROSPERO international prospective database of systematic reviews (CRD42021256939—05 July 2021). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04139-1.
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Stoppe C, Lee ZY, Lew CCH, Hill A, Ortiz-Reyes A, Heyland DK, Patel JJ. The authors reply. Crit Care Med 2022; 50:e720-e721. [PMID: 35984061 DOI: 10.1097/ccm.0000000000005600] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Aileen Hill
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Alfonso Ortiz-Reyes
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daren K Heyland
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jayshil J Patel
- Department of Critical Care Medicine, Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada
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Niemann B, Stoppe C, Wittenberg M, Rohrbach S, Saeed D, Billion M, Potapov E, Oezkur M, Akhyari P, Schmack B, Schibilsky D, Bernhardt AM, Schmitto JD, Hagl C, Masiello P, Böning A. Erratum to: Rational and Initiative of the Impella in Cardiac Surgery (ImCarS) Register Platform. Thorac Cardiovasc Surg 2022. [PMID: 35973777 DOI: 10.1055/s-0042-1755310] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
- Bernd Niemann
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Bavaria, Germany
- Abiomed, Abiomed, Danvers, Massachusetts, United States
| | - Michael Wittenberg
- Coordinating Center for Clinical Trials, Philipps-University of Marburg, Marburg, Hessia, Germany
| | - Susanne Rohrbach
- Institute of Physiology, Justus-Liebig-University Giessen, Giessen, Hessen, Germany
| | - Diyar Saeed
- Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael Billion
- Department of Cardiac Surgery, Schüchtermann Hospital Bad Rothenfelde, Bad Rothenfelde, Niedersachsen, Germany
| | - Evgenij Potapov
- Department of Cardiac Surgery, Deutsches Herzzentrum Berlin Ringgold Standard Institution, Berlin, Berlin, Germany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University of Mainz, Mainz, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Essen, Essen, Germany
| | - David Schibilsky
- Department of Cardiac Surgery, University of Freiburg, Freiburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Jan D Schmitto
- Department of Cardiac-, Thoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, München, Germany
| | - Paolo Masiello
- Department of Cardiac Surgery, San Giovanni di Dio e R.A. Hospital, Salerno, Salerno, Italy
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
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Lee ZY, Chin Han Lew C, Stoppe C, Hill A, Ortiz-Reyes A, Dhaliwal R, Heyland DK, Patel JJ. The authors reply. Crit Care Med 2022; 50:e691-e693. [PMID: 35838267 DOI: 10.1097/ccm.0000000000005573] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Charles Chin Han Lew
- Department of Dietetics and Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Aileen Hill
- Departments of Anesthesiology and Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Alfonso Ortiz-Reyes
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, KGH Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, KGH Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, KGH Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
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Niemann B, Stoppe C, Wittenberg M, Rohrbach S, Diyar S, Billion M, Potapov E, Oezkur M, Akhyari P, Schmack B, Schibilsky D, Bernhardt AM, Schmitto JD, Hagl C, Masiello P, Böning A. Rational and Initiative of the Impella in Cardiac Surgery (ImCarS) Register Platform. Thorac Cardiovasc Surg 2022; 70:458-466. [PMID: 35817063 DOI: 10.1055/s-0042-1749686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Cardiac support systems are being used increasingly more due to the growing prevalence of heart failure and cardiogenic shock. Reducing cardiac afterload, intracardiac pressure, and flow support are important factors. Extracorporeal membrane oxygenation (ECMO) and intracardiac microaxial pump systems (Impella) as non-permanent MCS (mechanical circulatory support) are being used increasingly. METHODS We reviewed the recent literature and developed an international European registry for non-permanent MCS. RESULTS Life-threatening conditions that are observed preoperatively often include reduced left ventricular function, systemic hypoperfusion, myocardial infarction, acute and chronic heart failure, myocarditis, and valve vitia. Postoperative complications that are commonly observed include severe systemic inflammatory response, ischemia-reperfusion injury, trauma-related disorders, which ultimately may lead to low cardiac output (CO) syndrome and organ dysfunctions, which necessitates a prolonged ICU stay. Choosing the appropriate device for support is critical. The management strategies and complications differ by system. The "heart-team" approach is inevitably needed.However despite previous efforts to elucidate these topics, it remains largely unclear which patients benefit from certain systems, when is the right time to initiate (MCS), which support system is appropriate, what is the optimal level and type of support, which therapeutic additive and supportive strategies should be considered and ultimately, what are the future prospects and therapeutic developments. CONCLUSION The European cardiac surgical register ImCarS has been established as an IIT with the overall aim to evaluate data received from the daily clinical practice in cardiac surgery. Interested colleagues are cordially invited to join the register. CLINICAL REGISTRATION NUMBER DRKS00024560. POSITIVE ETHICS VOTE AZ 246/20 Faculty of Medicine, Justus-Liebig-University-Gießen.
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Affiliation(s)
- Bernd Niemann
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Bavaria, Germany.,Abiomed, Abiomed, Danvers, Massachusetts, United States
| | - Michael Wittenberg
- Coordinating Center for Clinical Trials, Philipps-University of Marburg, Marburg, Hessia, Germany
| | - Susanne Rohrbach
- Institute of Physiology, Justus-Liebig-University Giessen, Giessen, Hessen, Germany
| | - Saeed Diyar
- Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael Billion
- Department of Cardiac Surgery, Schüchtermann Hospital Bad Rothenfelde, Bad Rothenfelde, Niedersachsen, Germany
| | - Evgenij Potapov
- Department of Cardiac Surgery, Deutsches Herzzentrum Berlin Ringgold Standard Institution, Berlin, Berlin, Germany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University of Mainz, Mainz, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Essen, Essen, Germany
| | - David Schibilsky
- Department of Cardiac Surgery, University of Freiburg, Freiburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Jan D Schmitto
- Department of Cardiac-, Thoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, München, Germany
| | - Paolo Masiello
- Department of Cardiac Surgery, San Giovanni di Dio e R.A. Hospital, Salerno, Salerno, Italy
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
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Patel NM, Yamada N, Oliveira FRMB, Stiehler L, Zechendorf E, Hinkelmann D, Kraemer S, Stoppe C, Collino M, Collotta D, Alves GF, Ramos HP, Sordi R, Marzi I, Relja B, Marx G, Martin L, Thiemermann C. Inhibition of Macrophage Migration Inhibitory Factor Activity Attenuates Haemorrhagic Shock-Induced Multiple Organ Dysfunction in Rats. Front Immunol 2022; 13:886421. [PMID: 35464452 PMCID: PMC9019168 DOI: 10.3389/fimmu.2022.886421] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/14/2022] [Indexed: 12/13/2022] Open
Abstract
Objective The aim of this study was to investigate (a) macrophage migration inhibitory factor (MIF) levels in polytrauma patients and rats after haemorrhagic shock (HS), (b) the potential of the MIF inhibitor ISO-1 to reduce multiple organ dysfunction syndrome (MODS) in acute (short-term and long-term follow-up) HS rat models and (c) whether treatment with ISO-1 attenuates NF-κB and NLRP3 activation in HS. Background The MODS caused by an excessive systemic inflammatory response following trauma is associated with a high morbidity and mortality. MIF is a pleiotropic cytokine which can modulate the inflammatory response, however, its role in trauma is unknown. Methods The MIF levels in plasma of polytrauma patients and serum of rats with HS were measured by ELISA. Acute HS rat models were performed to determine the influence of ISO-1 on MODS. The activation of NF-κB and NLRP3 pathways were analysed by western blot in the kidney and liver. Results We demonstrated that (a) MIF levels are increased in polytrauma patients on arrival to the emergency room and in rats after HS, (b) HS caused organ injury and/or dysfunction and hypotension (post-resuscitation) in rats, while (c) treatment of HS-rats with ISO-1 attenuated the organ injury and dysfunction in acute HS models and (d) reduced the activation of NF-κB and NLRP3 pathways in the kidney and liver. Conclusion Our results point to a role of MIF in the pathophysiology of trauma-induced organ injury and dysfunction and indicate that MIF inhibitors may be used as a potential therapeutic approach for MODS after trauma and/or haemorrhage.
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Affiliation(s)
- Nikita M Patel
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Noriaki Yamada
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.,Gifu University Graduate School of Medicine, Department of Emergency and Disaster Medicine Gifu University Hospital Advanced Critical Care Center, Gifu, Japan
| | - Filipe R M B Oliveira
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Lara Stiehler
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.,Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Elisabeth Zechendorf
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniel Hinkelmann
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Sandra Kraemer
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Anesthesiology & Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Massimo Collino
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Debora Collotta
- Department of Neurosciences "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Hanna Pillmann Ramos
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Regina Sordi
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany.,Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto-von-Guericke University, Magdeburg, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Lukas Martin
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom.,Department of Intensive Care and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Christoph Thiemermann
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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