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Pardo E, Jabaudon M, Godet T, Pereira B, Morand D, Futier E, Arpajou G, Le Cam E, Bonnet MP, Constantin JM. Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients. Clin Nutr 2024; 43:1343-1352. [PMID: 38677045 DOI: 10.1016/j.clnu.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND & AIMS Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients. METHODS This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance. RESULTS We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047). CONCLUSION Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.
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Affiliation(s)
- Emmanuel Pardo
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France.
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; Université Clermont Auvergne, Department of Healthcare Simulation, Clermont-Ferrand, F-63000, France; Université Clermont Auvergne, Inserm, Neuro-Dol, Clermont-Ferrand, F-63000, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Dominique Morand
- Direction de la Recherche Clinique (DRCI), CHU de Clermont-Ferrand, Clermont-Ferrand, F-63003, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Gauthier Arpajou
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Elena Le Cam
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France
| | - Marie-Pierre Bonnet
- Sorbonne Université, Département Anesthésie-Réanimation, Hôpital Armand Trousseau, DMU DREAM, GRC 29, AP-HP, Paris, France; Université Paris Cité, INSERM, INRA, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Maternité Port Royal, 53 Avenue de l'Observatoire, F-75014, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-hôpitaux de Paris, 75013, Paris, France
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de Man AME, Gunst J, Reintam Blaser A. Nutrition in the intensive care unit: from the acute phase to beyond. Intensive Care Med 2024:10.1007/s00134-024-07458-9. [PMID: 38771368 DOI: 10.1007/s00134-024-07458-9] [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: 12/27/2023] [Accepted: 04/21/2024] [Indexed: 05/22/2024]
Abstract
Recent randomized controlled trials (RCTs) have shown no benefit but dose-dependent harm by early full nutritional support in critically ill patients. Lack of benefit may be explained by anabolic resistance, suppression of cellular repair processes, and aggravation of hyperglycemia and insulin needs. Also early high amino acid doses did not provide benefit, but instead associated with harm in patients with organ dysfunctions. However, most studies focused on nutritional interventions initiated during the first days after intensive care unit admission. Although the intervention window of some RCTs extended into the post-acute phase of critical illness, no large RCTs studied nutritional interventions initiated beyond the first week. Hence, clear evidence-based guidance on when and how to initiate and advance nutrition is lacking. Prolonged underfeeding will come at a price as there is no validated metabolic monitor that indicates readiness for medical nutrition therapy, and an adequate response to nutrition, which likely varies between patients. Also micronutrient status cannot be assessed reliably, as inflammation can cause redistribution, so that plasma micronutrient concentrations are not necessarily reflective of total body stores. Moreover, high doses of individual micronutrients have not proven beneficial. Accordingly, current evidence provides clear guidance on which nutritional strategies to avoid, but the ideal nutritional regimen for individual patients remains unclear. In this narrative review, we summarize the findings of recent studies, discuss possible mechanisms explaining the results, point out pitfalls in interpretation of RCTs and their effect on clinical practice, and formulate suggestions for future research.
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Affiliation(s)
- Angelique M E de Man
- Department of Intensive Care, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
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3
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Frederiks P, Peetermans M, Wilmer A. Nutritional support in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:373-379. [PMID: 38333990 DOI: 10.1093/ehjacc/zuae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/10/2024]
Abstract
Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.
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Affiliation(s)
- Pascal Frederiks
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
| | - Marijke Peetermans
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Alexander Wilmer
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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4
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Wittholz K, Bongetti AJ, Fetterplace K, Caldow MK, Karahalios A, De Souza DP, Elahee Doomun SN, Rooyackers O, Koopman R, Lynch GS, Ali Abdelhamid Y, Deane AM. Plasma beta-hydroxy-beta-methylbutyrate availability after enteral administration during critical illness after trauma: An exploratory study. JPEN J Parenter Enteral Nutr 2024; 48:421-428. [PMID: 38522007 DOI: 10.1002/jpen.2622] [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: 12/07/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND During critical illness skeletal muscle wasting occurs rapidly. Although beta-hydroxy-beta-methylbutyrate (HMB) is a potential treatment to attenuate this process, the plasma appearance and muscle concentration is uncertain. METHODS This was an exploratory study nested within a blinded, parallel group, randomized clinical trial in which critically ill patients after trauma received enteral HMB (3 g daily) or placebo. Plasma samples were collected at 0, 60, and 180 min after study supplement administration on day 1. Needle biopsies of the vastus lateralis muscle were collected (baseline and day 7 of the HMB treatment intervention period). An external standard curve was used to calculate HMB concentrations in plasma and muscle. RESULTS Data were available for 16 participants (male n = 12 (75%), median [interquartile range] age 50 [29-58] years) who received placebo and 18 participants (male n = 14 (78%), age 49 [34-55] years) who received HMB. Plasma HMB concentrations were similar at baseline but increased after HMB (T = 60 min: placebo 0.60 [0.44-1.31] µM; intervention 51.65 [22.76-64.72] µM). Paired muscle biopsies were collected from 11 participants (placebo n = 7, HMB n = 4). Muscle HMB concentrations were similar at baseline between groups (2.35 [2.17-2.95]; 2.07 [1.78-2.31] µM). For participants in the intervention group who had the repeat biopsy within 4 h of HMB administration, concentrations were greater (7.2 and 12.3 µM) than those who had the repeat biopsy >4 h after HMB (2.7 and 2.1 µM). CONCLUSION In this exploratory study, enteral HMB administration increased plasma HMB availability. The small sample size limits interpretation of the muscle HMB findings.
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Affiliation(s)
- Kym Wittholz
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Amy J Bongetti
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Marissa K Caldow
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - David P De Souza
- Metabolomics Australia, Bio21 Institute, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Olav Rooyackers
- Division of Anesthesiology and Intensive Care, Department of Clinical Science, Technology and Intervention, Karolinska Institutet, Huddinge, Sweden
| | - René Koopman
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Gordon S Lynch
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Thawkar VN, Taksande K. Navigating Nutritional Strategies: Permissive Underfeeding in Critically Ill Patients. Cureus 2024; 16:e58083. [PMID: 38741818 PMCID: PMC11088961 DOI: 10.7759/cureus.58083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Nutritional support is a critical component of care for critically ill patients, impacting their recovery and overall prognosis. Traditional approaches to feeding in the intensive care unit (ICU) have focused on meeting estimated energy requirements, often resulting in unintended consequences such as overfeeding and associated complications. Permissive underfeeding, a concept gaining attention recently, offers a more controlled approach by intentionally providing fewer calories than traditionally recommended. This comprehensive review explores the rationale, evidence, and practical considerations surrounding permissive underfeeding in critically ill patients. We discuss the physiological basis of permissive underfeeding, its potential benefits in mitigating the risks of overfeeding, and the challenges associated with implementation in clinical practice. Through an analysis of critical studies and clinical trials, we evaluate the comparative effectiveness of permissive underfeeding versus traditional feeding methods and examine its impact on patient outcomes. Recommendations for patient selection, monitoring, and future research directions are provided to guide clinicians in optimizing nutritional support strategies for critically ill individuals. By considering the role of permissive underfeeding alongside traditional feeding approaches, healthcare professionals can tailor nutritional interventions to individual patient needs, ultimately improving outcomes in the ICU.
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Affiliation(s)
- Varun N Thawkar
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Karuna Taksande
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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6
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Deane AM, Casaer MP. Editorial: The interaction between protein delivery and blood urea and ammonia during critical illness. Curr Opin Clin Nutr Metab Care 2024; 27:144-146. [PMID: 38320160 DOI: 10.1097/mco.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Adam M Deane
- University of Melbourne, Melbourne Medical School, Department of Critical Care
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Nourse P, McCulloch M, Coetzee A, Bunchman T, Picca S, Rusch J, Brooks A, Heydenrych H, Morrow B. Protein loss and glucose absorption in children with AKI treated with peritoneal dialysis. Perit Dial Int 2024; 44:109-116. [PMID: 37970810 DOI: 10.1177/08968608231208322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Protein loss and glucose absorption in children on acute peritoneal dialysis (PD) is important to inform dietary prescription, yet data are lacking in this regard. This study was a secondary analysis of a previously published crossover randomised controlled trial, aiming to describe glucose uptake and protein loss into dialysate among children with acute kidney injury (AKI) receiving PD. METHODS This secondary analysis described and compared dialysate albumin loss and glucose absorption in 15 children with AKI receiving PD or continuous flow peritoneal dialysis (CFPD). In addition, correlations between albumin loss, glucose absorption and other patient and dialysis factors were analysed. RESULTS Median (range) age and weight of participants were 6.0 (0.2-14) months and 5.8 (2.3-14.0) kg, respectively. Patients received approximately 8 h of dialysis on each modality; however, results were extrapolated and expressed per day. The mean ± SD albumin loss on conventional PD and CFPD was 0.3 ± 0.19 g/kg/day and 0.56 ± 0.5 g/kg/day, respectively, and the mean ± SD glucose absorption was 4.67 ± 2.87 g/kg/day and 3.85 ±4.1 g/kg/day, respectively. There was a moderate correlation between ultrafiltration and albumin loss during CFPD only (Pearson's R = 0.61; p = 0.02). There were no significant differences between PD and CFPD for either glucose absorption or albumin loss; however, the study was not powered for this outcome. CONCLUSIONS Protein losses and glucose absorption in children on PD with AKI are significant and should be considered when prescribing nutritional content. Protein losses on CFPD were twice as high as on conventional PD.
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Affiliation(s)
- Peter Nourse
- Division of Pediatric Nephrology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Mignon McCulloch
- Division of Pediatric Nephrology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Ashton Coetzee
- Division of Pediatric Nephrology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | | | - Stefano Picca
- International Society of Nephrology, Brussels, Belgium
| | - Jody Rusch
- Division of Chemical Pathology, Department of Pathology, University of Cape Town, South Africa
| | - Andre Brooks
- Division of Cardio-Thoracic surgery, Department of Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Hilton Heydenrych
- Department of Chemical Engineering, University of Cape Town, South Africa
| | - Brenda Morrow
- Division of Paediatric Critical Care, Department of Paediatrics and Child Health, University of Cape Town, South Africa
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Coppens G, Vanhorebeek I, Güiza F, Derese I, Wouters PJ, Téblick A, Dulfer K, Joosten KF, Verbruggen SC, Van den Berghe G. Abnormal DNA methylation within HPA-axis genes years after paediatric critical illness. Clin Epigenetics 2024; 16:31. [PMID: 38395991 PMCID: PMC10893716 DOI: 10.1186/s13148-024-01640-y] [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: 11/02/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Critically ill children suffer from impaired physical/neurocognitive development 2 years later. Glucocorticoid treatment alters DNA methylation within the hypothalamus-pituitary-adrenal (HPA) axis which may impair normal brain development, cognition and behaviour. We tested the hypothesis that paediatric-intensive-care-unit (PICU) patients, sex- and age-dependently, show long-term abnormal DNA methylation within the HPA-axis layers, possibly aggravated by glucocorticoid treatment in the PICU, which may contribute to the long-term developmental impairments. RESULTS In a pre-planned secondary analysis of the multicentre PEPaNIC-RCT and its 2-year follow-up, we identified differentially methylated positions and differentially methylated regions within HPA-axis genes in buccal mucosa DNA from 818 former PICU patients 2 years after PICU admission (n = 608 no glucocorticoid treatment; n = 210 glucocorticoid treatment) versus 392 healthy children and assessed interaction with sex and age, role of glucocorticoid treatment in the PICU and associations with long-term developmental impairments. Adjusting for technical variation and baseline risk factors and correcting for multiple testing (false discovery rate < 0.05), former PICU patients showed abnormal DNA methylation of 26 CpG sites (within CRHR1, POMC, MC2R, NR3C1, FKBP5, HSD11B1, SRD5A1, AKR1D1, DUSP1, TSC22D3 and TNF) and three DNA regions (within AVP, TSC22D3 and TNF) that were mostly hypomethylated. These abnormalities were sex-independent and only partially age-dependent. Abnormal methylation of three CpG sites within FKBP5 and one CpG site within SRD5A1 and AKR1D1 was partly attributable to glucocorticoid treatment during PICU stay. Finally, abnormal methylation within FKBP5 and AKR1D1 was most robustly associated with long-term impaired development. CONCLUSIONS Two years after critical illness in children, abnormal methylation within HPA-axis genes was present, predominantly within FKBP5 and AKR1D1, partly attributable to glucocorticoid treatment in the PICU, and explaining part of the long-term developmental impairments. These data call for caution regarding liberal glucocorticoid use in the PICU.
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Affiliation(s)
- Grégoire Coppens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Inge Derese
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Karolijn Dulfer
- Division of Paediatric Intensive Care Unit, Department of Neonatal and Paediatric ICU, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Koen F Joosten
- Division of Paediatric Intensive Care Unit, Department of Neonatal and Paediatric ICU, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sascha C Verbruggen
- Division of Paediatric Intensive Care Unit, Department of Neonatal and Paediatric ICU, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Callahan JC, Parot-Schinkel E, Asfar P, Ehrmann S, Tirot P, Guitton C. Impact of daily cyclic enteral nutrition versus standard continuous enteral nutrition in critically ill patients: a study protocol for a randomised controlled trial in three intensive care units in France (DC-SCENIC). BMJ Open 2024; 14:e080003. [PMID: 38286683 PMCID: PMC10826523 DOI: 10.1136/bmjopen-2023-080003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/19/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Current guidelines on clinical nutrition of ventilated patients in the intensive care unit (ICU) recommend initiating continuous enteral nutrition within 48 hours of ICU admission when feasible. However, discontinuous feeding regimens, alternating feeding and fasting intervals, may have an impact on clinical and patient centred outcomes. The ongoing "Impact of daily cyclic enteral nutrition versus standard continuous enteral nutrition in critically ill patients" (DC-SCENIC) trial aims to compare standard continuous enteral feeding with daily cyclic enteral feeding over 10 hours to evaluate if implementing a fasting-mimicking diet can decrease organ failure in ventilated patients during the acute phase of ICU management. METHODS AND ANALYSIS DC-SCENIC is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients 18 years of age or older receiving invasive mechanical ventilation and having an indication for enteral nutrition through a gastric tube. Enteral feeding is continuous in the control group and administered over 10 hours daily in the intervention group. Both groups receive isocaloric nutrition with 4 g of protein per 100 mL, and have the same 20 kcal/kg/day caloric target. The primary endpoint is the change in the Sequential Organ Failure Assessment score at 7 days compared with the day of inclusion in the study. Secondary outcomes include daily caloric and protein delivery, digestive, respiratory and metabolic tolerance as well as 28-day mortality, duration of mechanical ventilation and ventilator-free days. Outcomes will be analysed on an intention-to-treat basis. Recruitment started in June 2023 in 3 French ICU's and a sample size of 318 patients is expected by February 2026. ETHICS AND DISSEMINATION This study received approval from the national ethics review board on 8 November 2022 (Comité de Protection des Personnes Sud-Est VI, registration number 2022-A00827-36). Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05627167.
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Affiliation(s)
| | - Elsa Parot-Schinkel
- Biostatistics and Methodology Department, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Stephan Ehrmann
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Patrice Tirot
- Service de Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | - Christophe Guitton
- Service de Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
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Haines RW, Prowle JR, Day A, Bear DE, Heyland DK, Puthucheary Z. Association between urea trajectory and protein dose in critically ill adults: a secondary exploratory analysis of the effort protein trial (RE-EFFORT). Crit Care 2024; 28:24. [PMID: 38229072 PMCID: PMC10792897 DOI: 10.1186/s13054-024-04799-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Delivering higher doses of protein to mechanically ventilated critically ill patients did not improve patient outcomes and may have caused harm. Longitudinal urea measurements could provide additional information about the treatment effect of higher protein doses. We hypothesised that higher urea values over time could explain the potential harmful treatment effects of higher doses of protein. METHODS We conducted a reanalysis of a randomised controlled trial of higher protein doses in critical illness (EFFORT Protein). We applied Bayesian joint models to estimate the strength of association of urea with 30-day survival and understand the treatment effect of higher protein doses. RESULTS Of the 1301 patients included in EFFORT Protein, 1277 were included in this analysis. There were 344 deaths at 30 days post-randomisation. By day 6, median urea was 2.1 mmol/L higher in the high protein group (95% CI 1.1-3.2), increasing to 3.0 mmol/L (95% CI 1.3-4.7) by day 12. A twofold rise in urea was associated with an increased risk of death at 30 days (hazard ratio 1.34, 95% credible interval 1.21-1.48), following adjustment of baseline characteristics including age, illness severity, renal replacement therapy, and presence of AKI. This association persisted over the duration of 30-day follow-up and in models adjusting for evolution of organ failure over time. CONCLUSIONS The increased risk of death in patients randomised to a higher protein dose in the EFFORT Protein trial was estimated to be mediated by increased urea cycle activity, of which serum urea is a biological signature. Serum urea should be taken into consideration when initiating and continuing protein delivery in critically ill patients. CLINICALTRIALS gov Identifier: NCT03160547 (2017-05-17).
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Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston Health Science Center, Kingston, ON, Canada
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
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11
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Rivas García F, Martínez RJG, Camarasa FJH, Cerdá JCM, Messeguer FL, Gallardo MLV. A Narrative Review: Analysis of Supplemental Parenteral Nutrition in Adults at the End of Life. Pharmaceuticals (Basel) 2023; 17:65. [PMID: 38256898 PMCID: PMC10820363 DOI: 10.3390/ph17010065] [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: 11/06/2023] [Revised: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
"End of life" is a stage defined by the existence of an irreversible prognosis that ends with a person's death. One of the aspects of interest regarding end of life focuses on parenteral nutrition, which is usually administered in order to avoid malnutrition and associated complications. However, parenteral nutrition can be adapted to specific circumstances and evolve in its functionality through supplementation with certain nutrients that can have a beneficial effect. This narrative review aims to carry out a situation analysis of the role that could be adopted by supplemental parenteral nutrition in attenuating alterations typical of end of life and potential improvement in quality of life.
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12
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Lauwers C, De Bruyn L, Langouche L. Impact of critical illness on cholesterol and fatty acids: insights into pathophysiology and therapeutic targets. Intensive Care Med Exp 2023; 11:84. [PMID: 38015312 PMCID: PMC10684846 DOI: 10.1186/s40635-023-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
Critical illness is characterized by a hypercatabolic response encompassing endocrine and metabolic alterations. Not only the uptake, synthesis and metabolism of glucose and amino acids is majorly affected, but also the homeostasis of lipids and cholesterol is altered during acute and prolonged critical illness. Patients who suffer from critically ill conditions such as sepsis, major trauma, surgery or burn wounds display an immediate and sustained reduction in low plasma LDL-, HDL- and total cholesterol concentrations, together with a, less pronounced, increase in plasma free fatty acids. The severity of these alterations is associated with severity of illness, but the underlying pathophysiological mechanisms are multifactorial and only partly clarified. This narrative review aims to provide an overview of the current knowledge of how lipid and cholesterol uptake, synthesis and metabolism is affected during critical illness. Reduced nutritional uptake, increased scavenging of lipoproteins as well as an increased conversion to cortisol or other cholesterol-derived metabolites might all play a role in the decrease in plasma cholesterol. The acute stress response to critical illness creates a lipolytic cocktail, which might explain the increase in plasma free fatty acids, although reduced uptake and oxidation, but also increased lipogenesis, especially in prolonged critical illness, will also affect the circulating levels. Whether a disturbed lipid homeostasis warrants intervention or should primarily be interpreted as a signal of severity of illness requires further research.
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Affiliation(s)
- Caroline Lauwers
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 Box 503, 3000, Leuven, Belgium
| | - Lauren De Bruyn
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 Box 503, 3000, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, O&N1 Box 503, 3000, Leuven, Belgium.
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13
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Ait Hssain A, Farigon N, Merdji H, Guelon D, Bohé J, Cayot S, Chabanne R, Constantin JM, Pereira B, Bouvier D, Andant N, Roth H, Thibault R, Sapin V, Hasselmann M, Souweine B, Cano N, Boirie Y, Dupuis C. Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study. Clin Nutr 2023; 42:2070-2079. [PMID: 37708587 DOI: 10.1016/j.clnu.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/20/2023] [Accepted: 09/02/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND & AIMS After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay. METHODS This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality. RESULTS 572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%. CONCLUSION BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.
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Affiliation(s)
- Ali Ait Hssain
- Department of Intensive Care, Medical Intensive Care, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Nicolas Farigon
- Department of Clinical Nutrition, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Hamid Merdji
- Department of Intensive Care, Medical Intensive Care, Nouvel Hôpital Civil, Strasbourg University, Strasbourg, France; INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg University, Strasbourg, France
| | - Dominique Guelon
- Department of Perioperative Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Julien Bohé
- Service D'Anesthésie-Réanimation-Médecine Intensive, Groupement Hospitalier Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Sophie Cayot
- Department of Perioperative Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Russel Chabanne
- Department of Perioperative Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France; Réanimation Chirurgicale Polyvalente, GH Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research and Innovation, Clermont Ferrand University, Clermont-Ferrand, France
| | - Damien Bouvier
- Department of Medical Biochemistry and Molecular Genetics, Clermont Ferrand University Hospital, Clermont-Ferrand, France
| | - Nicolas Andant
- Biostatistics Unit, Department of Clinical Research and Innovation, Clermont Ferrand University, Clermont-Ferrand, France
| | - Hubert Roth
- University Grenoble Alpes and Inserm U1055, Laboratory of Fundamental and Applied Bioenergetics (LBFA) and SFR Environmental and Systems Biology (BEeSy), 38059 Grenoble, France
| | - Ronan Thibault
- Service D'Endocrinologie-Diabétologie-Nutrition, Centre Labellisé de Nutrition Parentérale Au Domicile, CHU Rennes, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer Institute, NuMeCan, Rennes, France
| | - Vincent Sapin
- Department of Medical Biochemistry and Molecular Genetics, Clermont Ferrand University Hospital, Clermont-Ferrand, France
| | - Michel Hasselmann
- Department of Intensive Care, Medical Intensive Care, Nouvel Hôpital Civil, Strasbourg University, Strasbourg, France; INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg University, Strasbourg, France
| | - Bertrand Souweine
- Department of Intensive Care, Medical Intensive Care, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Clermont Auvergne University, CNRS, LMGE, F-63000 Clermont-Ferrand, France
| | - Noël Cano
- Department of Clinical Nutrition, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Clermont Auvergne University, Human Nutrition Unit, INRAE, CRNH Auvergne, Clermont-Ferrand, France
| | - Yves Boirie
- Department of Clinical Nutrition, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Clermont Auvergne University, Human Nutrition Unit, INRAE, CRNH Auvergne, Clermont-Ferrand, France
| | - Claire Dupuis
- Department of Intensive Care, Medical Intensive Care, Clermont-Ferrand University Hospital, Clermont-Ferrand, France; Clermont Auvergne University, Human Nutrition Unit, INRAE, CRNH Auvergne, Clermont-Ferrand, France.
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14
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Reintam Blaser A, Rooyackers O, Bear DE. How to avoid harm with feeding critically ill patients: a synthesis of viewpoints of a basic scientist, dietitian and intensivist. Crit Care 2023; 27:258. [PMID: 37393289 PMCID: PMC10314407 DOI: 10.1186/s13054-023-04543-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/22/2023] [Indexed: 07/03/2023] Open
Abstract
The optimal feeding strategy in critically ill patients is a matter of debate, with current guidelines recommending different strategies regarding energy and protein targets. Several recent trials have added to the debate and question our previous understanding of the provision of nutrition during critical illness. This narrative review aims to provide a summary of interpretation of recent evidence from the view of basic scientist, critical care dietitian and intensivist, resulting in joined suggestions for both clinical practice and future research. In the most recent randomised controlled trial (RCT), patients receiving 6 versus 25 kcal/kg/day by any route achieved readiness for ICU discharge earlier and had fewer GI complications. A second showed that high protein dosage may be harmful in patients with baseline acute kidney injury and more severe illness. Lastly, a prospective observational study using propensity score matched analysis suggested that early full feeding, especially enteral, compared to delayed feeding is associated with a higher 28-day mortality. Viewpoints from all three professionals point to the agreement that early full feeding is likely harmful, whereas important questions regarding the mechanisms of harm as well as on timing and optimal dose of nutrition for individual patients remain unanswered and warrant future studies. For now, we suggest giving low dose of energy and protein during the first few days in the ICU and apply individualised approach based on assumed metabolic state according to the trajectory of illness thereafter. At the same time, we encourage research to develop better tools to monitor metabolism and the nutritional needs for the individual patient accurately and continuously.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, 50406, Tartu, Estonia.
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Olav Rooyackers
- Division of Anesthesiology and Intensive Care, Department of Clinical Science, Technology and Intervention, Karolinska Institutet, Huddinge, Sweden
| | - Danielle E Bear
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
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15
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Umbrello M, Marini JJ, Formenti P. Metabolic Support in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2023; 12:jcm12093216. [PMID: 37176655 PMCID: PMC10179727 DOI: 10.3390/jcm12093216] [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: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Nutritional support for acute respiratory distress syndrome (ARDS) patients shares metabolic notions common to other critically ill conditions. Nevertheless, it generates specific concern regarding the primary limitation of oxygen supply and the complications of carbon dioxide elimination, as well as the significant metabolic alterations due to the body's response to illness. In the present narrative review, after briefly summarizing the pathophysiology of critical illness stress response and patients' metabolic requirements, we focus on describing the characteristics of metabolic and artificial nutrition in patients with acute respiratory failure. In patients with ARDS, several aspects of metabolism assume special importance. The physiological effects of substrate metabolism are described for this setting, particularly regarding energy consumption, diet-induced thermogenesis, and the price of their clearance, transformation, and storage. Moreover, we review the possible direct effects of macronutrients on lung tissue viability during ARDS. Finally, we summarize the noteworthy characteristics of metabolic control in critically ill patients with ARDS and offer a suggestion as to the ideal methods of metabolic support for this problem.
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Affiliation(s)
- Michele Umbrello
- Unità Operativa di Anestesia e Rianimazione II, Ospedaliera San Carlo, ASST Santi Paolo e Carlo, 20148 Milan, Italy
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, 20097 Cinisello Balsamo, Italy
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