Summary
Close liaison with ICU‐trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients– this should be done while monitoring closely for ...refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient‐centred outcomes including complications and mortality. Obesity is part of that story, and isocaloric and high‐protein provision of nutrition is important in this group of patients who comprise a growing proportion of people treated. Assessing protein stores and appropriate dosing is, however, challenging in all groups of patients. It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post‐pyloric feeding and a multidisciplinary framework to support the importance of nutritional education.
Critically ill patients lose up to 2% of muscle mass per day. We assessed the feasibility of administering a leucine-enriched essential amino acid (L-EAA) supplement to mechanically ventilated trauma ...patients with the aim of assessing the effect on skeletal muscle mass and function.
A randomised feasibility study was performed over six months in intensive care (ICU). Patients received 5 g L-EAA five times per day in addition to standard feed (L-EAA group) or standard feed only (control group) for up to 14 days. C-reactive protein, albumin, IL-6, IL-10, urinary 3-MH, nitrogen balance, protein turnover (1-13C leucine infusion), muscle depth change (ultrasound), functional change (Katz and Barthel indices) and muscle strength Medical Research Council (MRC) sum score to assess ICU Acquired Weakness were measured sequentially.
Eight patients (9.5% of screened patients) were recruited over six months. L-EAA doses were provided on 91/124 (73%) occasions. Inflammatory and urinary marker data were collected; serial muscle depth measurements were lacking due to short length of stay. Protein turnover studies were performed on five occasions. MRC sum score could not be performed as patients were not able to respond to the screening questions. The Katz and Barthel indices did not change. L-EAA delivery was achievable, but meaningful functional and muscle mass outcome measures require careful consideration in the design of a future randomised controlled trial.
L-EAA was practical to provide, but we found significant barriers to recruitment and measurement of the chosen outcomes which would need to be addressed in the design of a future, large randomised controlled trial.
ISRCTN Registry, ISRCTN79066838 . Registered on 25 July 2012.
Muscle wasting during critical illness impairs recovery. Dietary strategies to minimise wasting include nutritional supplements, particularly essential amino acids. We reviewed the evidence on ...enteral supplementation with amino acids or their metabolites in the critically ill and in muscle wasting illness with similarities to critical illness, aiming to assess whether this intervention could limit muscle wasting in vulnerable patient groups. Citation databases, including MEDLINE, Web of Knowledge, EMBASE, the meta‐register of controlled trials and the Cochrane Collaboration library, were searched for articles from 1950 to 2013. Search terms included ‘critical illness’, ‘muscle wasting’, ‘amino acid supplementation’, ‘chronic obstructive pulmonary disease’, ‘chronic heart failure’, ‘sarcopenia’ and ‘disuse atrophy’. Reviews, observational studies, sport nutrition, intravenous supplementation and studies in children were excluded. One hundred and eighty studies were assessed for eligibility and 158 were excluded. Twenty‐two studies were graded according to standardised criteria using the GRADE methodology: four in critical care populations, and 18 from other clinically relevant areas. Methodologies, interventions and outcome measures used were highly heterogeneous and meta‐analysis was not appropriate. Methodology and quality of studies were too varied to draw any firm conclusion. Dietary manipulation with leucine enriched essential amino acids (EAA), β‐hydroxy‐β‐methylbutyrate and creatine warrant further investigation in critical care; EAA has demonstrated improvements in body composition and nutritional status in other groups with muscle wasting illness. High‐quality research is required in critical care before treatment recommendations can be made.
Background
Critical illness is associated with muscle loss, weakness and poor recovery. The impact that illness and the ensuing metabolic response has on obese patients is not known. Objectives were ...to test if obese patients lose less muscle depth compared to non‐obese patients; if a reduction in muscle depth was associated with reduced strength and recovery; and to assess the feasibility of these methods with a range of body mass index's (BMI).
Methods
A prospective observational pilot study of muscle depth in critically ill patients categorised by BMI was performed. Muscle depth changes were assessed by ultrasound on study days 1, 3, 5, 7, 12 and 14. Strength was measured via handgrip dynamometry and Medical Research Council (MRC) sum score on waking and at discharge from the intensive care unit. Level of dependency was measured with the Barthel index.
Results
44 critically ill patients; 17 had normal BMI, 10 were overweight and 17 were obese. The three groups did not differ in baseline characteristics, except obese patients had significantly greater initial muscle depth. Muscle depth loss was similar between the BMI groups at each of the time points. Handgrip and MRC sum score were only possible in a small number of patients because of reduced alertness and weakness. Majority were deemed fully dependent based on the Barthel index.
Conclusions
Obese patients lost muscle depth in a comparable manner to non‐obese patients, suggesting that BMI may not prevent muscle depth loss. It was not possible to determine the effect on strength because the clinical condition of patients precluded reliable measurements.
Background: Critically ill patients frequently receive inadequate nutrition support as a result of under‐ or overfeeding. Malnutrition in intensive care unit (ICU) patients is associated with ...increased morbidity and mortality. The present study aimed to identify the significant factors that influence energy deficit in the ICU.
Methods: ICU patients with a length of stay of ≥3 days were studied for 30 days over two consecutive years at a large university teaching hospital. Fifty‐six Patients were studied, with a total of 530 records of feeding days. Information was collected for: day when feed initiated, age, gender, length of stay, Acute Physiological and Chronic Health Evaluation score (APACHE II), fed within 24 h, speciality, type of ventilation, feeding route, outcome (survived/died), diarrhoea (yes/no), aspirate volume, dietitian observed nutritional status (malnourished/not), sedation, estimated energy requirements and energy received. Mixed linear models for longitudinal data were used with energy deficit (energy received – energy requirements) as the dependent variable.
Results: Factors that were found to have a significant association with energy deficit were: day feeding was initiated (P < 0.001), whether fed within 24 h (P < 0.001) and whether sedated (P < 0.001). Furthermore, three combined effects were found: ventilation mode and aspirate volume (P < 0.007), fed within 24 h and ventilation mode (P < 0.001), fed within 24 h and sedation (P < 0.017).
Conclusions: The number of days after feeding was initiated, initiation of feeding within 24 h and sedation have been identified as factors that predict energy deficit during ICU stay. Efforts to initiate feeding as soon as possible and minimise interruptions to feeding may reduce energy deficits in these vulnerable patients.
The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest ...base camp (5,300 m).
A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls.
Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p < .0001), but was otherwise not consistently associated with socio-demographic, mood, or physiological variables.
After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The 'Cytocam' is a third generation video-microscope, which enables real time visualisation of the in vivo microcirculation. Based upon the principle of incident dark field (IDF) illumination, this ...hand held computer-controlled device was designed to address the technical limitations of its predecessors, orthogonal polarization spectroscopy and sidestream dark field (SDF) imaging. In this manuscript, we aimed to compare the quality of sublingual microcirculatory image acquisition between the IDF and SDF devices.
Using the microcirculatory image quality scoring (MIQS) system, (six categories scored as either 0 = optimal, 1 = acceptable, or 10 = unacceptable), two independent raters compared 30 films acquired using the Cytocam IDF video-microscope, to an equal number obtained with an SDF device. Blinded to the origin of the films, the raters were therefore able to score between 0 and 60 for each film analysed. The scores' distributions between the two techniques were compared.
The median MIQS (95% CI) given to the SDF camera was 7 (1.5-12), as compared to 1 (0.5-1.0) for the IDF device (p < 0.0001). Of the six categories assessed by the MIQS, nearly one fifth of the SDF videos were scored as unacceptable for pressure (20%), content (20%), and stability (17%), with focus scoring deficiently 13% of the time. High agreement between the two raters scoring values was evident, with an intra-class correlation coefficient (ICC) of 0.96 (95% CI: 0.94, 0.98).
These results demonstrate that the quality of sublingual microcirculatory image acquisition is superior in the Cytocam IDF video-microscope, as compared to the SDF video-microscope.
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