Nutrition may be important for recovery from critical illness. Gastrointestinal dysfunction is a key barrier to nutrition delivery in the Intensive Care Unit (ICU) and metabolic rate is elevated ...exacerbating nutritional deficits. Whether these factors persist following ICU discharge is unknown. We assessed whether delayed gastric emptying (GE) and impaired glucose absorption persist post-ICU discharge.
A prospective observational study was conducted in mechanically ventilated adults at 3 time-points: in ICU (V1); on the post-ICU ward (V2); and 3-months after ICU discharge (V3); and compared to age-matched healthy volunteers. On each visit, all participants received a test-meal containing 100 ml of 1 kcal/ml liquid nutrient, labelled with 0.1 g 13C-octanoic acid and 3 g 3-O-Methyl-glucose (3-OMG), and breath and blood samples were collected over 240min to quantify GE (gastric emptying coefficient (GEC)), and glucose absorption (3-OMG concentration; area under the curve (AUC)). Data are mean ± standard error of the mean (SEM) and differences shown with 95% confidence intervals (95%CI).
Twenty-six critically ill patients completed V1 (M:F 20:6; 62.0 ± 2.9 y; BMI 29.8 ± 1.2 kg/m2; APACHE II 19.7 ± 1.9), 15 completed V2 and eight completed V3; and were compared to 10 healthy volunteers (M:F 6:4; 60.5 ± 7.5 y; BMI 26.0 ± 1.0 kg/m2). GE was significantly slower on V1 compared to health (GEC difference: −0.96 (95%CI -1.61, −0.31); and compared to V2 (−0.73 (−1.16, −0.31) and V3 (−1.03 (−1.47, −0.59). GE at V2 and V3 were not different to that in health (V2: −0.23 (−0.61, 0.14); V3: 0.10 (−0.27, 0.46)). GEC: V1: 2.64 ± 0.19; V2: 3.37 ± 0.12; V3: 3.67 ± 0.10; health: 3.60 ± 0.13. Glucose absorption (3-OMG AUC0-240) was impaired on V1 compared to V2 (−37.9 (−64.2, −11.6)), and faster on V3 than in health (21.8 (0.14, 43.4) but absorption at V2 and V3 did not differ from health. Intestinal glucose absorption: V1: 63.8 ± 10.4; V2: 101.7 ± 7.0; V3: 111.9 ± 9.7; health: 90.7 ± 3.8.
This study suggests that delayed GE and impaired intestinal glucose absorption recovers rapidly post-ICU. This requires further confirmation in a larger population.
The REINSTATE trial was prospectively registered at www.anzctr.org.au.
ACTRN12618000370202.
Background
Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group.
Objective
To quantify energy intake and ...potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers.
Design
A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test‐meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition‐impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range IQR) or number percentage).
Results
Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS‐CoV‐2. Energy intake was lower in both patient groups than in health (ICU: 289 288, 809, GM: 426 336, 592, health: 815 654, 1165 kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 7.0, 11.0, 8.5 7.0, 9.5, and 8.0 6.0, 11.0; and QoL; 60 40–65, 50 31–55, and 90 81–95 out of 100.
Conclusions
Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.
Critically ill patients who do not receive invasive mechanical ventilation (IMV) are a growing population, experiencing complex interventions that may impair dietary intake and nutrition-related ...outcomes.
The objectives of this study were to quantify intake and nutrition-related outcomes of non-IMV critically ill patients and to establish feasibility of methods to measure nutrition-related outcomes in this population.
Non-IMV adult patients expected to remain in the intensive care unit (ICU) for ≥24 h were eligible. Nutrition-related outcomes were assessed at baseline by subjective global assessment (SGA); on alternate study days by mid-upper arm circumference (MUAC), calf circumference (CC), and ultrasound of quadriceps muscle layer thickness (QMLT); and daily by body weight and bioelectrical impedance analysis (BIA). Data were censored at day 5 or ICU discharge. Dietary intake from all sources, including oral intake via investigator-led weighed food records, was quantified on days 1–3. Feasibility was defined as data completion rate ≥70%. Data are expressed as mean (standard deviation) or median interquartile range (IQR).
Twenty-three patients consented (50% male; 53 42–64 y; ICU stay: 2.8 1.9–4.0 d). Nutrition-related outcomes at baseline and ICU discharge were as follows: MUAC: 33.2 (8.6) cm (n = 18) and 29.3 (5.4) cm (n = 6); CC: 39.5 (7.4) cm (n = 16) and 37.5 (6.2) cm (n = 6); body weight: 95.3 (34.8) kg (n = 19) and 95.6 (41.0) kg (n = 10); and QMLT: 2.6 (0.8) cm (n = 15) and 2.5 (0.3) cm (n = 5), respectively. Oral intake provided 3155 1942–5580 kJ and 32 20–53 g protein, with poor appetite identified as a major barrier. MUAC, CC, QMLT, and SGA were feasible, while BIA and body weight were not.
Oral intake in critically ill patients not requiring IMV is below estimated requirements, largely because of poor appetite. The small sample and short study duration were not sufficient to quantify changes in nutrition-related outcomes. MUAC, CC, QMLT, and SGA are feasible methods to assess nutrition-related outcomes at a single time point in this population.
Nutritional needs of trauma patients admitted to the intensive care unit may differ from general critically ill patients, but most current evidence is based on large clinical trials recruiting mixed ...populations.
The aim of the study was to investigate nutrition practices at two time points that span a decade in trauma patients with and without head injury.
This observational study recruited adult trauma patients receiving mechanical ventilation and artificial nutrition from a single-centre intensive care unit between February 2005 to December 2006 (cohort 1), and December 2018 to September 2020 (cohort 2). Patients were categorised into head injury and non–head injury subgroups. Data regarding energy and protein prescription and delivery were collected. Data are presented as median interquartile range. Wilcoxon rank-sum test assessed the differences between cohorts and subgroups, with a P value ≤ 0.05. The protocol was registered with the Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001816246).
Cohort 1 included 109 patients, and 112 patients were included in cohort 2 (age: 46 ± 19 vs 50 ± 19 y; 80 vs 79% M). Overall, nutrition practice did not differ between head-injured and non–head-injured subgroups (all P > 0.05). Energy prescription and delivery decreased from time point one to time point two, regardless of subgroup (Prescription: 9824 8820–10 581 vs 8318 7694–9071 kJ; Delivery: 6138 5130–7188 vs 4715 3059–5996 kJ; all P < 0.05). Protein prescription did not change from time point one to time point two. Although protein delivery remained constant from time point one to time point two in the head injury group, protein delivery reduced in the non–head injury subgroup (70 56–82 vs 45 26–64 g/d, P < 0.05).
In this single-centre study, energy prescription and delivery in critically ill trauma patients reduced from time point one to time point two. Protein prescription did not change, but protein delivery reduced from time point one to time point two in non–head injury patients. Reasons for these differing trajectories require exploration.
Trial registered at www.anzctr.org.au. Trial ID: ACTRN12618001816246.
Background
Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a ...lack of data regarding in‐hospital outcomes and resource utilization in the setting of cardiogenic shock (CS).
Hypothesis
Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients.
Methods
The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD‐9 and ICD‐10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in‐hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05).
Results
We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints.
Conclusions
These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under‐diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long‐term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.
Key points
Unhoused patients hospitalized with cardiogenic shock (CS) have fewer traditional comorbidities however similar in‐hospital outcomes compared to housed patients.
Unhoused patients with CS receive left and right heart catheterization and mechanical circulatory support less frequently than housed patients, however, undergo endotracheal intubation with greater frequency.
A multidisciplinary approach along with strong community partnerships may result in improved access to care for this vulnerable population.
For the Western North America Mercury Synthesis, we compiled mercury records from 165 dated sediment cores from 138 natural lakes across western North America. Lake sediments are accepted as faithful ...recorders of historical mercury accumulation rates, and regional and sub-regional temporal and spatial trends were analyzed with descriptive and inferential statistics. Mercury accumulation rates in sediments have increased, on average, four times (4×) from 1850 to 2000 and continue to increase by approximately 0.2μg/m2 per year. Lakes with the greatest increases were influenced by the Flin Flon smelter, followed by lakes directly affected by mining and wastewater discharges. Of lakes not directly affected by point sources, there is a clear separation in mercury accumulation rates between lakes with no/little watershed development and lakes with extensive watershed development for agricultural and/or residential purposes. Lakes in the latter group exhibited a sharp increase in mercury accumulation rates with human settlement, stabilizing after 1950 at five times (5×) 1850 rates. Mercury accumulation rates in lakes with no/little watershed development were controlled primarily by relative watershed size prior to 1850, and since have exhibited modest increases (in absolute terms and compared to that described above) associated with (regional and global) industrialization. A sub-regional analysis highlighted that in the ecoregion Northwestern Forest Mountains, <1% of mercury deposited to watersheds is delivered to lakes. Research is warranted to understand whether mountainous watersheds act as permanent sinks for mercury or if export of “legacy” mercury (deposited in years past) will delay recovery when/if emissions reductions are achieved.
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•We compiled Hg records from lakes across western North America.•Hg accumulation rates increased, on average, four times from 1850 to 2000.•Regional and global emissions of Hg to the atmosphere result in enhanced Hg deposition.•Watershed disturbance exacerbates the problem, by reducing the retention of Hg in soils.•Hg deposition rates are highest near urban areas, where watershed disturbance is greatest.
Abstract only Introduction: Pre-orthotropic liver transplant (OLT) cardiac risk assessment commonly focuses on evaluation of coronary artery disease (CAD). However, the effect of atrial fibrillation ...(AF) on post-OLT outcomes is less well known. In this study, we sought to evaluate the prevalence and effect of pre-transplant AF on 30-day post-operative outcomes in patients undergoing OLT. Methods: The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and -10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. Results: Among 45,357 patients who underwent OLT, 35.8 % were women. The prevalence of AF prior to transplant was 2,932 (6.5%) with a trend towards increasing prevalence between 2011 and 2017 with an annual change rate of 4.19%, see Figure 1. Compared to the non-AF cohort, the AF group was older (59.9±7.9 vs 51.2±16.9 years old, p<0.001), with a higher prevalence of diabetes mellitus (DM), CAD, chronic kidney disease, heart failure (HF), anemia, and thrombocytopenia (p<0.001 for all). In-hospital 30-day mortality (5.8% vs. 3.6%, p<0.001), intra-operative cardiac arrest (8.1% vs. 1.7%, p<0.001), post-operative ventricular tachycardia (7.5% vs. 2.6%, p<0.001) and acute kidney injury (64.2% vs. 49.3%, p<0.001) were higher in the AF group when compared to those without. Using a multivariate logistic regression model to adjust for confounding factors, AF was still predictive of an increased odds of in-hospital 30-day mortality (OR: 1.92; 95% CI 1.61-2.30, p<0.001). Conclusion: In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with worse in-hospital outcomes and 30-day mortality. This effect may be driven in part by a higher prevalence of concurrent cardiovascular disease and associated risk factors in patients with AF. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.
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