What’s new in trace elements? Singer, Pierre; Manzanares, William; Berger, Mette M.
Intensive care medicine,
05/2018, Volume:
44, Issue:
5
Journal Article
Peer reviewed
Trace elements (TE), namely selenium (Se), zinc (Zn), copper (Cu), iodine (I), molybdenum (Mo), chromium (Cr), iron (Fe), and manganese (Mn), are essential in daily nutritional care of the critically ...ill 1 and should be administered daily (normal values are presented in Table 1). Their deficiency may be lethal if uncorrected. Because of their potential antioxidant functions 2, TEhave been administered alone or in association, sometimes at high doses, in specific critical conditions, to improve outcome. Special conditions such as burns, fistulas, or renal replacement therapy involve large losses and have specific requirements. Special needs/utilization of TE are discussed.
Summary Background & aims The Swiss supplemental parenteral nutrition (SPN) study demonstrated that optimised energy provision combining enteral nutrition (EN) and SPN reduces nosocomial infections ...in critically ill adults who fail to achieve targeted energy delivery with EN alone. To assess the economic impact of this strategy, we performed a cost-effectiveness analysis using data from the SPN study. Methods Multivariable regression analyses were performed to characterise the relationships between SPN, cumulative energy deficit, nosocomial infection, and resource consumption. The results were used as inputs for a deterministic simulation model evaluating the cost-effectiveness of SPN administered on days 4–8 in patients who fail to achieve ≥60% of targeted energy delivery with EN by day 3. Cost data were derived primarily from Swiss diagnosis-related case costs and official labour statistics. Results Provision of SPN on days 4–8 was associated with a mean decrease of 2320 ± 338 kcal in cumulative energy deficit compared with EN alone (p < 0.001). Logistic regression analysis showed that each 1000 kcal decrease in cumulative energy deficit was associated with a 10% reduction in the risk of nosocomial infection (odds ratio 0.90; 95% confidence interval 0.83–0.99; p < 0.05). The incremental cost per avoided infection was −63,048 CHF, indicating that the reduction in infection was achieved at a lower cost. Conclusion Optimisation of energy provision using SPN is a cost-saving strategy in critically ill adults for whom EN is insufficient to meet energy requirements.
The ICALIC project was initiated for developing an accurate, reliable and user friendly indirect calorimeter (IC) and aimed at evaluating its ease of use and the feasibility of the EE measurements in ...intensive care unit (ICU).
This was a prospective unblinded, observational, multi-center study. Simultaneous IC measurements in mechanically ventilated ICU patients were performed using the new IC (Q-NRG®) and currently used devices. Time required to obtain EE was recorded to evaluate the ease of use of Q-NRG® versus currently used ICs and EE measurements were compared. Conventional descriptive statistics were used: data as mean ± SD.
Six centers out of nine completed the required number of patients for the primary analysis. Mean differences in the time needed by Q-NRG® against currently used ICs were −32.3 ± 2.5 min in Geneva (vs. Deltatrac®; p < 0.01), −32.3 ± 3.1 in Lausanne (vs. Quark RMR®; p < 0.05), −33.7 ± 1.4 in Brussels (vs. V-Max Encore®; p < 0.05), −26.4 ± 7.8 in Tel Aviv (vs. Deltatrac®; p < 0.05), −28.5 ± 3.5 in Vienna (vs. Deltatrac®; p < 0.05), and 0.3 ± 1.2 in Chiba (vs. E-COVX®; p = 0.17). EE (kcal/day) measurements by the Q-NRG® were similar to the Deltatrac® in Geneva and Vienna (mean differences±SD: −63.1 ± 157.8 (p = 0.462) and −22.9 ± 328.2 (=0.650)), but significantly different in Tel Aviv (307.4 ± 324.5, p < 0.001). Significant differences were observed in Lausanne (Quark RMR®: −224.4 ± 514.9, p = 0.038) and in Brussels (V-max®: −449.6 ± 667.4, p < 0.001), but none was found in Chiba (E-COVX®; 55.0 ± 204.1, p = 0.165).
The Q-NRG® required a much shorter time than most other ICs to determine EE in mechanically ventilated ICU patients. The Q-NRG® is the only commercially available IC tested against mass spectrometry to ensure gas accuracy, while being very easy-to use.
Gastrointestinal failure is a polymorphic syndrome with multiple causes. Managing the different situations from a practical, metabolic, and nutritional point of view is challenging, which the present ...review will try to address.
Acute gastrointestinal injury (AGI) has been defined and has evolved into a concept of gastrointestinal dysfunction score (GIDS) built on the model of Sequential Organ Failure Assessment (SOFA) score, and ranging from 0 (no risk) to 4 (life threatening). But there is yet no specific, reliable and reproducible, biomarker linked to it. Evaluating the risk with the Nutrition Risk Screening (NRS) score is the first step whenever addressing nutrition therapy. Depending on the severity of the gastrointestinal failure and its clinical manifestations, nutritional management needs to be individualized but always including prevention of undernutrition and dehydration, and administration of target essential micronutrients. The use of fibers in enteral feeding solutions has gained acceptance and is even recommended based on microbiome findings. Parenteral nutrition whether alone or combined to enteral feeding is indicated whenever the intestine is unable to process the needs.
The heterogeneity of gastrointestinal insufficiency precludes a uniform nutritional management of all critically ill patients but justifies its early detection and the implementation of individualized care.
Critical illness is associated with the generation of oxygen free radicals and low endogenous antioxidant capacity leading to a condition of oxidative stress. We investigated whether supplementing ...critically ill patients with antioxidants, trace elements, and vitamins improves their survival.
We searched four bibliographic databases from 1980 to 2003 and included studies that were randomized, reported clinically important endpoints in critically ill patients, and compared various trace elements and vitamins to placebo.
Eleven articles met the inclusion criteria. When the results of all the trials were aggregated, overall antioxidants were associated with a significant reduction in mortality Risk Ratio (RR) 0.65, 95% confidence intervals (CI) 0.44-0.97, p=0.03 but had no effect on infectious complications. Studies that utilized a single trace element were associated with a significant reduction in mortality RR 0.52, 95% CI 0.27-0.98, p=0.04 whereas combined antioxidants had no effect. Studies using parenteral antioxidants were associated with a significant reduction in mortality RR 0.56, 95% CI 0.34-0,92, p=0.02 whereas studies of enteral antioxidants were not. Selenium supplementation (alone and in combination with other antioxidants) may be associated with a reduction in mortality RR 0.59, 95% CI 0.32-1.08, p=0.09 while nonselenium antioxidants had no effect on mortality.
Trace elements and vitamins that support antioxidant function, particularly high-dose parenteral selenium either alone or in combination with other antioxidants, are safe and may be associated with a reduction in mortality in critically ill patients.
The optimal feeding strategy for critically ill patients is still debated, but feeding must be adapted to individual patient needs. Critically ill patients are at risk of muscle catabolism, leading ...to loss of muscle mass and its consequent clinical impacts. Timing of introduction of feeding and protein targets have been explored in recent trials. These suggest that "moderate" protein provision (maximum 1.2 g/kg/day) is best during the initial stages of illness. Unresolved inflammation may be a key factor in driving muscle catabolism. The omega-3 (n-3) fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are substrates for synthesis of mediators termed specialized pro-resolving mediators or SPMs that actively resolve inflammation. There is evidence from other settings that high-dose oral EPA + DHA increases muscle protein synthesis, decreases muscle protein breakdown, and maintains muscle mass. SPMs may be responsible for some of these effects, especially upon muscle protein breakdown. Given these findings, provision of EPA and DHA as part of medical nutritional therapy in critically ill patients at risk of loss of muscle mass seems to be a strategy to prevent the persistence of inflammation and the related anabolic resistance and muscle loss.
After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting ...variability of clinical practice is confirmed and results in difficult comparisons between burn centers.
Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.
Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.
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