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Li P, Li S, Liu S, Li M. Modified Nutrition Risk in the Critically ill score and mortality in critically ill patients with traumatic brain injury. Nutr Clin Pract 2023; 38:1032-1044. [PMID: 37255501 DOI: 10.1002/ncp.11014] [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: 12/09/2022] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Understanding the relationship between nutrition risk at admission to the intensive care unit (ICU) and the prognosis of patients with traumatic brain injury (TBI) may aid early recognition of high-risk patients. METHODS We extracted data from the Medical Information Mart for Intensive Care III and the electronic ICU Collaborative Research Databases. Using modified Nutrition Risk in the Critically ill score (mNUTRIC) within the first 24 h of ICU admission, 5153 patients were divided into three groups: low (≤1, n = 1765), moderate (2-4, n = 2574), and high (≥5, n = 814). The primary outcome was 28-day in-hospital mortality, and the secondary outcomes were 7-day in-hospital mortality, length of ICU stay, and duration of mechanical ventilation. RESULTS During the median follow-up time of 6.69 days, 647 deaths occurred in total. After adjustment for potential confounding factors, setting the low mNUTRIC group as a reference, the risk of 28-day mortality was increased in the high and moderate mNUTRIC groups (hazard ratio [HR]high vs low [95% CI]: 4.21 [2.70-6.58] and 2.84 [1.95-4.14], respectively). Similarly, high and moderate mNUTRIC scores are linked to a higher risk of 7-day mortality (PTrend < 0.001) and a longer duration of mechanical ventilation (PTrend < 0.001). The effect of mNUTRIC on mortality varied by serum glucose level (PInteraction = 0.01). Lastly, those whose mNUTRIC scores deteriorated within the first 3 days have a 1.46 times greater risk of dying compared with patients with improved mNUTRIC scores. CONCLUSIONS Nutrition risk screening by mNUTRIC score at the time of admission to the ICU may improve mortality prediction.
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Affiliation(s)
- Ping Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Sikai Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
| | - Shanshan Liu
- Department of Critical Illness, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Man Li
- Key Laboratory of Biomedical Imaging of Guangdong Province, Guangdong Provincial Engineering Research Center of Molecular Imaging, The Fifth Affiliated Hospital at Sun Yat-sen University, Zhuhai, Guangdong, China
- Center for Interventional Medicine, The Fifth Affiliated Hospital at Sun Yat-Sen University, Zhuhai, Guangdong, China
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Elliott JE, Keil AT, Mithani S, Gill JM, O’Neil ME, Cohen AS, Lim MM. Dietary Supplementation With Branched Chain Amino Acids to Improve Sleep in Veterans With Traumatic Brain Injury: A Randomized Double-Blind Placebo-Controlled Pilot and Feasibility Trial. Front Syst Neurosci 2022; 16:854874. [PMID: 35602971 PMCID: PMC9114805 DOI: 10.3389/fnsys.2022.854874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Study Objectives Traumatic brain injury (TBI) is associated with chronic sleep disturbances and cognitive impairment. Our prior preclinical work demonstrated dietary supplementation with branched chain amino acids (BCAA: leucine, isoleucine, and valine), precursors to de novo glutamate production, restored impairments in glutamate, orexin/hypocretin neurons, sleep, and memory in rodent models of TBI. This pilot study assessed the feasibility and preliminary efficacy of dietary supplementation with BCAA on sleep and cognition in Veterans with TBI. Methods Thirty-two Veterans with TBI were prospectively enrolled in a randomized, double-blinded, placebo-controlled trial comparing BCAA (30 g, b.i.d. for 21-days) with one of two placebo arms (microcrystalline cellulose or rice protein, both 30 g, b.i.d. for 21-days). Pre- and post-intervention outcomes included sleep measures (questionnaires, daily sleep/study diaries, and wrist actigraphy), neuropsychological testing, and blood-based biomarkers related to BCAA consumption. Results Six subjects withdrew from the study (2/group), leaving 26 remaining subjects who were highly adherent to the protocol (BCAA, 93%; rice protein, 96%; microcrystalline, 95%; actigraphy 87%). BCAA were well-tolerated with few side effects and no adverse events. BCAA significantly improved subjective insomnia symptoms and objective sleep latency and wake after sleep onset on actigraphy. Conclusion Dietary supplementation with BCAA is a mechanism-based, promising intervention that shows feasibility, acceptability, and preliminary efficacy to treat insomnia and objective sleep disruption in Veterans with TBI. A larger scale randomized clinical trial is warranted to further evaluate the efficacy, dosing, and duration of BCAA effects on sleep and other related outcome measures in individuals with TBI. Clinical Trial Registration [http://clinicaltrials.gov/], identifier [NCT03990909].
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Affiliation(s)
- Jonathan E. Elliott
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | | | - Sara Mithani
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Jessica M. Gill
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Maya E. O’Neil
- VA Portland Health Care System, Portland, OR, United States,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States,Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
| | - Akiva S. Cohen
- Perelman School of Medicine, Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, United States,Anesthesiology, Children’s Hospital of Philadelphia, Joseph Stokes Research Institute, Philadelphia, PA, United States
| | - Miranda M. Lim
- VA Portland Health Care System, Portland, OR, United States,Department of Neurology, Oregon Health & Science University, Portland, OR, United States,Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, United States,Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, United States,VA Portland Health Care System, National Center for Rehabilitation and Auditory Research, Portland, OR, United States,*Correspondence: Miranda M. Lim,
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Foley N, Marshall S, Pikul J, Salter K, Teasell R. Hypermetabolism following Moderate to Severe Traumatic Acute Brain Injury: A Systematic Review. J Neurotrauma 2008; 25:1415-31. [DOI: 10.1089/neu.2008.0628] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Norine Foley
- Aging, Rehabilitation & Geriatric Care Program, Lawson Health Research Institute, Parkwood Hospital, London, Ontario, Canada
| | - Shawn Marshall
- Department of Medicine, University of Ottawa, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - Jill Pikul
- Critical Care, Trauma and Transplant Program, London Health Sciences Centre, University Campus, London, Ontario, Canada
| | - Katherine Salter
- Aging, Rehabilitation & Geriatric Care Program, Lawson Health Research Institute, Parkwood Hospital, London, Ontario, Canada
| | - Robert Teasell
- Department of Physical Medicine and Rehabilitation, Parkwood Hospital, London, Ontario, Canada
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Krakau K, Omne-Pontén M, Karlsson T, Borg J. Metabolism and nutrition in patients with moderate and severe traumatic brain injury: A systematic review. Brain Inj 2006; 20:345-67. [PMID: 16716982 DOI: 10.1080/02699050500487571] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PRIMARY OBJECTIVE To examine the evidence on the metabolic state and nutritional treatment of patients with moderate-to-severe traumatic brain injury (TBI). RESEARCH DESIGN A systematic review of the literature. METHODS AND PROCEDURES From 1547 citations, 232 articles were identified and retrieved for text screening. Thirty-six studies fulfilled the criteria and 30 were accepted for data extraction. MAIN OUTCOMES AND RESULTS Variations in measurement methods and definitions of metabolic abnormalities hampered comparison of studies. However, consistent data demonstrated increased metabolic rate (96-160% of the predicted values), of hypercatabolism (-3 to -16 g N per day) and of upper gastrointestinal intolerance in the majority of the patients during the first 2 weeks after injury. Data also indicated a tendency towards less morbidity and mortality in early fed patients. CONCLUSIONS The impact of timing, content and ways of administration of nutritional support on neurological outcome after TBI remains to be demonstrated.
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Affiliation(s)
- Karolina Krakau
- Centre for Clinical Research Dalarna, Dummy institution, Sweden.
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Abstract
Severe head injuries tend to be associated with hypermetabolism and hypercatabolism resulting in negative nitrogen balances which may exceed 30 grams day-1. Enteral feeding should begin as soon as the patient is hemodynamically stable, attempting to reach a non-protein caloric intake of at least 30-35 kcal kg-1 day-1 and a protein intake of 2.0-2.5 g kg-1 day-1 as soon as possible. With severe head injuries (Glasgow Coma Scale < 8), there is an increased tendency for gastric feeding to regurgitate into the upper airway. Keeping the patient upright and checking residuals is important in such patients. Jejunal feedings are less apt to be aspirated. If it is apparent that the gastro-intestinal tract cannot be used to reach the nutritional goals within three days, total parental nutrition is begun within 24-48 h so as to reach these nutrition goals by either one or both routes by the third or fourth day. Blood glucose levels exceeding 150-200 mg dl-1 tend to increase the severity of the neurologic problems and efforts should be made to prevent hyperglycemia by carefully regulating the glucose and insulin intake. Indirect calorimetry to determine the respiratory quotient and resting energy expenditure should be determined twice weekly. To determine N2 balance, urinary urea nitrogen should be measured in 24-h specimens. These tests should be performed once or twice weekly until it is clear that the nutrition is adequate.
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Affiliation(s)
- R F Wilson
- Wayne State University School of Medicine, Detroit Receiving Hospital, Department of Surgery, 4201 St. Antoine, Suite 4V-23, Detroit, MI 48201, USA
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Stover JF, Kempski OS. Glutamate-containing parenteral nutrition doubles plasma glutamate: a risk factor in neurosurgical patients with blood-brain barrier damage? Crit Care Med 1999; 27:2252-6. [PMID: 10548216 DOI: 10.1097/00003246-199910000-00031] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Animal studies have shown that the elevation of plasma glutamate levels increase cerebral edema formation whenever the blood-brain barrier is disturbed. Therefore, changes in plasma glutamate levels as influenced by the administration of a glutamate-containing amino acid solution were investigated in neurosurgical patients. DESIGN Prospective, descriptive study. SETTING Eight-bed neurosurgical intensive care unit in a university hospital. PATIENTS Twenty-three neurosurgical patients requiring parenteral nutrition. INTERVENTIONS Parenteral nutrition was begun 24 hrs after craniotomy. Patients receiving a glutamate-containing amino acid solution (3.75 g/L glutamate) were compared with patients infused with a glutamate-free solution. MEASUREMENTS AND MAIN RESULTS Arterial plasma and urine amino acids were analyzed using high-performance liquid chromatography. Administration of a glutamate-containing solution doubled plasma glutamate levels in neurosurgical patients (from 53.3 +/- 9.8 microM [preinfusion] to 98.5 +/- 18.7 microM [after 4 hrs of infusion]; p < 0.001), whereas no elevation was seen when infusing a glutamate-free solution (from 52.3 +/- 7.3 [1 hr of infusion] to 53.6 +/- 6.4 microM [4 hrs of infusion]). Upon terminating the glutamate-containing infusion, arterial plasma glutamate levels decreased immediately (from 120 +/- 13.2 microM to 81.2 +/- 19.5 microM). Glutamate as infused in excess appears to exceed a renal threshold and is eliminated renally. CONCLUSIONS As shown in animal models, administration of a glutamate-containing amino acid solution significantly increased plasma glutamate levels. Because such an increase in plasma glutamate levels could aggravate cerebral edema formation, glutamate-containing amino acid solutions cannot be recommended for patients with a disturbed blood-brain barrier.
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Affiliation(s)
- J F Stover
- Institute for Neurosurgical Pathophysiology, Johannes Gutenberg University, Mainz, Germany
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Barratt SM, Smith RC, Kee AJ, Carlsson AR, Mather LE, Cousins MJ. Epidural analgesia reduces the release of amino acids from peripheral tissues in the ebb phase of the metabolic response to major upper abdominal surgery. Anaesth Intensive Care 1999; 27:26-32. [PMID: 10050219 DOI: 10.1177/0310057x9902700105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this prospective cohort study was to compare metabolic effects of epidural or patient controlled analgesia (PCA) in patients undergoing major upper abdominal surgery. Seventeen patients undergoing major upper abdominal surgery were included: 10 received perioperative epidural analgesia (Group I) and the remainder received morphine via a PCA device for postoperative analgesia (Group II). A number of measures compared between one day preoperatively (day 1) and day 2 postoperatively included femoral arterial and venous blood concentrations of glucose, lactate, pyruvate and amino acids. In addition, the relevant flux values were measured from the products of the respective arteriovenous substrate concentration differences and calf blood flow. The efflux of lactate from peripheral tissues was greater in Group II than in Group I (P < 0.01): glucose and pyruvate efflux did not differ between groups. There was no difference between groups in mean individual and total flux of amino acids on day-1. However increased efflux between day-1 and day 2 was found for alanine, valine, isoleucine, leucine, phenylalanine, lysine, arginine in both groups, and for serine, glycine, tyrosine and histidine in Group II (P < 0.05). The efflux of glycine, methionine, amino benzoic acid, alanine, and lysine was less in Group I than Group II on day 2 (P < 0.05). There was a significant difference in the total amino acid flux on day 2 (Group I = -1.2 mumol. (100 ml tissue)-1.min-1 cf Group II = -2.5 mumol. (100 ml tissue)-1.min-1; P = 0.04). In conclusion, perioperative epidural analgesia was associated with a reduced postoperative amino acid efflux two days following major upper abdominal surgery.
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Affiliation(s)
- S M Barratt
- Department of Anaesthesia, University of Sydney, Royal North Shore Hospital, St Leonards, N.S.W
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