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Halim Z, Huang Y, Lee ZY, Lew CCH. New randomized controlled trials on micronutrients in critical care nutrition: A narrative review. Nutr Clin Pract 2024. [PMID: 39119820 DOI: 10.1002/ncp.11195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 05/14/2024] [Accepted: 07/02/2024] [Indexed: 08/10/2024] Open
Abstract
There has been increasing interest in the role of micronutrient supplementation in critical care. This narrative review summarizes the recent studies on micronutrients in critically ill patients. We searched two databases for primary randomized controlled trials that investigated the effects of micronutrient supplementation in patients with critical illness published from January 2021 to August 2023. Personal files, reference lists of included studies, and previous reviews were also screened. Twelve studies reported on vitamin C, four studies on vitamin D, three studies on thiamin, two studies on multivitamins, and one study on cobalamin. The therapeutic effects of vitamin C appear mixed, although vitamin C monotherapy appears more promising than vitamin C combination therapy. Intramuscular administration of vitamin D appeared to lower mortality, mechanical ventilation duration, and intensive care unit stay, whereas enteral administration showed limited clinical benefits. Intravenous thiamin was not associated with improved outcomes in patients with septic shock or hypophosphatemia. Preliminary evidence suggests reduced vasopressor dose with cobalamin. Decreased disease severity and hospital stay in patients with COVID-19 with vitamins A-E requires further investigation, whereas providing solely B-group vitamins did not demonstrate therapeutic effects. It is currently premature to endorse the provision of high-dose micronutrients in critical illness to improve clinical outcomes. This review may help to inform the design of future trials that will help better elucidate the optimal dosage and form of micronutrients, methods of administration, and subgroups of patients with critical illness who may most benefit.
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Affiliation(s)
- Zakiah Halim
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Yingxiao Huang
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Germany
| | - Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore
- Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
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Xu Y, Qian Y, Liang P, Liu N, Dong D, Gu Q, Tang J. Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study. Am J Med Sci 2024:S0002-9629(24)01362-4. [PMID: 39033818 DOI: 10.1016/j.amjms.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 07/10/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients. METHODS We conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed. RESULTS In total, 162 patients were included and divided into delirium (n=54) and nondelirium (n=108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients. CONCLUSION The incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.
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Affiliation(s)
- Ying Xu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Yajun Qian
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Pei Liang
- Pharmacy Department, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Ning Liu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Danjiang Dong
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Qin Gu
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
| | - Jian Tang
- Department of Intensive Care Unit, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China.
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Cobilinschi C, Andrei CA, Grinţescu IM, Mirea L. Metabolic failure due to thiamine deficiency during critical illness. Curr Opin Clin Nutr Metab Care 2024; 27:155-162. [PMID: 38205831 DOI: 10.1097/mco.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
PURPOSE OF REVIEW Thiamine is a crucial component in cellular energy metabolism, serving as a cofactor for multiple enzymatic processes and also having a role in regulating neuronal and neuromuscular transmission. Also it exerts antioxidant proprieties. The objective of this review is to consolidate and assess the most recent research concerning the consequences of insufficient thiamine levels for critically ill patients and to examine thiamine-related interventions. RECENT FINDINGS Recent studies have unveiled a noteworthy association between thiamine deficiency and unfavorable consequences, such as heightened morbidity and fatality rates. The aforementioned deficiency exhibits a significant presence in medical situations such as starvation and alcohol use disorder, but also in patients during critical illness. Thiamine deficiency can have significant metabolic implications resulting in compromised energy generation and organ dysfunction, warranting prompt recognition and management. SUMMARY Thiamine deficiency may not be recognized in critical care. Timely identification and management are imperative to mitigate adverse outcomes and improve patient prognosis. Thiamine may offer benefits for specific patient groups at higher risk of deficiency. Future studies should focus to establish optimal dosing, timing, and monitoring strategies on understanding the pathophysiological changes associated with thiamine deficiency in ICU patients and clarify its role in improving clinical outcomes.
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Affiliation(s)
- Cristian Cobilinschi
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cosmin-Andrei Andrei
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ioana Marina Grinţescu
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Liliana Mirea
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Berger MM, Amrein K, Barazzoni R, Bindels L, Bretón I, Calder PC, Cappa S, Cuerda C, D'Amelio P, de Man A, Delzenne NM, Forbes A, Genton L, Gombart AF, Joly F, Laviano A, Matthys C, Phyo PP, Ravasco P, Serlie MJ, Shenkin A, Stoffel NU, Talwar D, van Zanten ARH. The science of micronutrients in clinical practice - Report on the ESPEN symposium. Clin Nutr 2024; 43:268-283. [PMID: 38104489 DOI: 10.1016/j.clnu.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium. METHODS Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency. RESULTS The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem. CONCLUSION Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome.
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Affiliation(s)
- Mette M Berger
- Lausanne University, Faculty of Biology & Medicine, 1005 Lausanne, Switzerland.
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria.
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
| | - Laure Bindels
- Faculty of Pharmacy and Biomedical Sciences, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Irene Bretón
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK.
| | - Stefano Cappa
- IUSS Cognitive Neuroscience (ICoN) Center, University School for Advanced Studies (IUSS-Pavia), 27100 Pavia, Italy.
| | - Cristina Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Patrizia D'Amelio
- Service de gériatrie et réadaptation gériatrique, Département de Médecine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Angélique de Man
- Department of Intensive Care Medicine, Research VUMC Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands.
| | - Nathalie M Delzenne
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Laurence Genton
- Clinical Nutrition Unit, Department of Endocrinology, Geneva University Hospitals, Geneva, Switzerland.
| | - Adrian F Gombart
- Linus Pauling Institute, Department of Biochemistry and Biophysics, Oregon State University, Corvallis, OR 97331, USA.
| | - Francisca Joly
- Beaujon Hospital, APHP, Clichy, University of Paris VII, France.
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, University La Sapienza, Rome, Italy.
| | | | - Pyi Pyi Phyo
- WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe, Copenhagen, Denmark.
| | - Paula Ravasco
- Coordinator of the Curricular Units Diabetes, Obesity and Lifestyle, Digestion and Defence, University of Lisbon - Católica Medical School, Lisbon, Portugal.
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Alan Shenkin
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Nicole U Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.
| | - Dinesh Talwar
- Department of Biochemistry, Glasgow Royal Infirmary, Glasgow, UK.
| | - Arthur R H van Zanten
- Gelderse Vallei Hospital, Ede and Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, the Netherlands.
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Collie JTB, Jiang A, Abdelhamid YA, Ankravs M, Bellomo R, Byrne KM, Clancy A, Finnis ME, Greaves R, Tascone B, Deane AM. Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness. J Hum Nutr Diet 2023; 36:1214-1224. [PMID: 36919646 DOI: 10.1111/jhn.13162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients. METHODS Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group. RESULTS Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25). CONCLUSIONS Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.
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Affiliation(s)
- Jake T B Collie
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Agilent Technologies, Melbourne, Victoria, Australia
| | - Alice Jiang
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa Ankravs
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Kathleen M Byrne
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Annabelle Clancy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark E Finnis
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ronda Greaves
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Department of Biochemical Genetics, Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brianna Tascone
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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