Hyperglycemia, hypoglycemia and increased glucose variability are independently associated with increased risk of death in critically ill adults. The relationship between time in targeted blood ...glucose range (TIR) and mortality is not well described and may be a factor that has confounded the results of the major interventional trials of intensive insulin therapy.
We conducted a retrospective analysis of prospectively collected data involving 3,297 patients with intensive care unit (ICU) lengths of stay (LOS) of ≥ 1.0 day who were admitted between 1 January 2009 and 31 December 2013 to a single mixed medical-surgical ICU. We investigated the relationship between TIR 70 to 140 mg/dl with mortality and compared outcomes of non-diabetics (NON) and individuals with diabetes mellitus (DM), including stratifying by TIR above (TIR-hi) and below (TIR-lo) the median value for the NON and DM groups.
There were 85,799 blood glucose (BG) values for the NON group and 32,651 for the DM group, and we found that 75.5% and 54.8%, respectively, were between 70 and 140 (P < 0.0001). The median (interquartile range) TIR (%) values for the NON and DM groups were 80.6% (61.4% to 94.0%) and 55.0% (35.5% to 71.1%), respectively (P < 0.0001). For the NON group, mortality was 8.47% and 15.71% for TIR-hi and TIR-lo, respectively (P < 0.0001). For the DM group, mortality was 16.09% and 14.44% for TIR-hi and TIR-lo, respectively (P = NS). We observed similar relationships for the NON group when we stratified by ICU LOS or severity of illness, especially in the most severely ill patients. There was a cumulative interaction of indices of hypoglycemia, hyperglycemia or glucose variability with TIR. Multivariable analysis demonstrated, for the NON group, that TIR-hi was independently associated with increased survival (P = 0.0019). For the NON group, the observed-to-expected mortality ratios for TIR-hi and TIR-lo, based on Acute Physiology and Chronic Health Evaluation IV methodology, were 0.53 and 0.78, respectively. In contrast, among those in the DM group, there was no clear relationship between TIR 70 to 140 mg/dl and survival.
Independently of ICU LOS and severity of illness, TIR 70 to 140 mg/dl > 80% is strongly associated with survival in critically ill patients without diabetes. These findings have implications for the design of clinical protocols for glycemic control in critically ill patients as well for the design of future interventional trials of intensive insulin therapy.
The rationale for the provision of nitrogen from proteins given via the enteral route or from intravenous amino acids is to boost the synthesis of muscle proteins, and thereby to limit the severity ...of intensive care unit-acquired weakness by the prevention of muscle loss. However, the optimal timing for supplemental nitrogen provision is a matter of debate and controversy. Indeed, consistent data from retrospective studies support an association between high early protein intakes and better outcomes, while recent post-hoc findings from prospective studies raise safety concerns. This pro-con paper details the arguments of both sides and highlights the need for large-scale prospective studies assessing the safety and efficacy of different levels of protein intake in combination with physical activity and summarizes the currently recruiting clinical trials.
Oxidative Stress Preiser, Jean-Charles
JPEN, Journal of parenteral and enteral nutrition/JPEN. Journal of parenteral and enteral nutrition,
March 2012, Volume:
36, Issue:
2
Journal Article
Peer reviewed
Open access
Oxidative stress is defined by an imbalance between increased levels of reactive oxygen species (ROS) and a low activity of antioxidant mechanisms. An increased oxidative stress can induce damage to ...the cellular structure and potentially destroy tissues. However, ROS are needed for adequate cell function, including the production of energy by the mitochondria. Increased oxidative stress has been incriminated in physiological conditions, such as aging and exercise, and in several pathological conditions, including cancer, neurodegenerative diseases, cardiovascular diseases, diabetes, inflammatory diseases, and intoxications. However, prevention by antioxidants has been mostly inefficient. Therefore, a rigorous scientific evaluation in well-defined conditions is mandatory to define the appropriate place for manipulations of the oxidative pathways in human medicine.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. ...Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Summary Results of randomised controlled trials of tight glycaemic control in hospital inpatients might vary with population and disease state. Individualised therapy for different hospital inpatient ...populations and identification of patients at risk of hyperglycaemia might be needed. One risk factor that has received much attention is the presence of pre-existing diabetes. So-called stress hyperglycaemia is usually defined as hyperglycaemia resolving spontaneously after dissipation of acute illness. The term generally refers to patients without known diabetes, although patients with diabetes might also develop stress hyperglycaemia—a fact overlooked in many studies comparing hospital inpatients with or without diabetes. Investigators of several studies have suggested that patients with stress hyperglycaemia are at higher risk of adverse consequences than are those with pre-existing diabetes. We describe classification of stress hyperglycaemia, mechanisms of harm, and management strategies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The estimation of caloric needs of critically ill patients is usually based on energy expenditure (EE), while current recommendations for caloric intake most often rely on a fixed amount of calories. ...In fact, during the early phase of critical illness, caloric needs are probably lower than EE, as a substantial proportion of EE is covered by the non-inhibitable endogenous glucose production. Hence, the risk of overfeeding is higher during the early phase than the late phase, while the risk of underfeeding is higher during the late phase of critical illness. Therefore, an accurate measurement of EE can be helpful to prevent early overfeeding and late underfeeding. Available techniques to assess EE include predictive equations, calorimetry, and doubly labeled water, the reference method. The available predictive equations are often inaccurate, while indirect calorimetry is difficult to perform for several reasons, including a shortage of reliable devices and technical limitations. In this review, the authors intend to discuss the different techniques and the influence of the method used on the interpretation of the results of clinical studies.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Background: Critically ill patients commonly experience skeletal muscle wasting that may predict clinical outcome. Ultrasound is a noninvasive method that can measure muscle quadriceps muscle layer ...thickness (QMLT) and subsequently lean body mass (LBM) at the bedside. However, currently the reliability of these measurements are unknown. The objectives of this study were to evaluate the intra- and interreliability of measuring QMLT using bedside ultrasound. Methods: Ultrasound measurements of QMLT were conducted at 7 centers on healthy volunteers. Trainers were instructed to perform measurements twice on each patient, and then a second trainee repeated the measurement. Intrarater reliability measured how consistently the same person measured the subject according to intraclass correlation (ICC). Interrater reliability measured how consistently trainer and trainee agreed when measuring the same subject according to the ICC. Results: We collected 42 pairs of within operator measurements with an ICC of .98 and 78 pairs of trainer-to-trainee measurements with an ICC of .95. There were no statistically significant differences between the trainer and trainee results (trainer and trainee mean = −0.028 cm, 95% CI = −0.067 to −0.011, P = .1607). Conclusions: Excellent intra- and interrater reliability for ultrasound measurements of QMLT in healthy volunteers was observed when performed by a range of providers with no prior ultrasound experience, including dietitians, nurses, physicians, and research assistants. This technique shows promise as a method to evaluate LBM status in ICU or hospital settings and as a method to assess the effects of nutrition and exercise-based interventions on muscle wasting.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Intensive care survivors often experience post-intensive care sequelae, which are frequently gathered together under the term "post-intensive care syndrome" (PICS). The consequences of PICS on ...quality of life, health-related costs and hospital readmissions are real public health problems. In the present Viewpoint, we summarize current knowledge and gaps in our understanding of PICS and approaches to management.
Objective
Previous studies have unveiled a relationship between the severity of coronavirus disease 2019 (COVID‐19) pneumonia and obesity. The aims of this multicenter retrospective cohort study were ...to disentangle the association of BMI and associated metabolic risk factors (diabetes, hypertension, hyperlipidemia, and current smoking status) in critically ill patients with COVID‐19.
Methods
Patients admitted to intensive care units for COVID‐19 in 21 centers (in Europe, Israel, and the United States) were enrolled in this study between February 19, 2020, and May 19, 2020. Primary and secondary outcomes were the need for invasive mechanical ventilation (IMV) and 28‐day mortality, respectively.
Results
A total of 1,461 patients were enrolled; the median (interquartile range) age was 64 years (40.9‐72.0); 73.2% of patients were male; the median BMI was 28.1 kg/m2 (25.4‐32.3); a total of 1,080 patients (73.9%) required IMV; and the 28‐day mortality estimate was 36.1% (95% CI: 33.0‐39.5). An adjusted mixed logistic regression model showed a significant linear relationship between BMI and IMV: odds ratio = 1.27 (95% CI: 1.12‐1.45) per 5 kg/m2. An adjusted Cox proportional hazards regression model showed a significant association between BMI and mortality, which was increased only in obesity class III (≥40; hazard ratio = 1.68 95% CI: 1.06‐2.64).
Conclusions
In critically ill COVID‐19 patients, a linear association between BMI and the need for IMV, independent of other metabolic risk factors, and a nonlinear association between BMI and mortality risk were observed.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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