ORCID Profile
0000-0002-7620-5577
Current Organisations
University of Brussels and University of Liege
,
University of Brussels
,
FNRS
,
University of Melbourne
,
Royal Melbourne Hospital
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Publisher: Springer Science and Business Media LLC
Date: 2009
DOI: 10.1186/CC7874
Publisher: Springer Science and Business Media LLC
Date: 13-07-2023
DOI: 10.1007/S11154-023-09823-3
Abstract: Background and aims : Bariatric surgery is the most effective treatment in in iduals with obesity to achieve remission of type 2 diabetes. Post-bariatric surgery hypoglycaemia occurs frequently, and management remains suboptimal, because of a poor understanding of the underlying pathophysiology. The glucoregulatory hormone responses to nutrients in in iduals with and without post-bariatric surgery hypoglycaemia have not been systematically examined. Materials and methods : The study protocol was prospectively registered with PROSPERO. PubMed, EMBASE, Web of Science and the Cochrane databases were searched for publications between January 1990 and November 2021 using MeSH terms related to post-bariatric surgery hypoglycaemia. Studies were included if they evaluated in iduals with post-bariatric surgery hypoglycaemia and included measurements of plasma glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), insulin, C-peptide and/or glucagon concentrations following an ingested nutrient load. Glycated haemoglobin (HbA 1c ) was also evaluated. A random-effects meta-analysis was performed, and Hedges’ g (standardised mean difference) and 95% confidence intervals were reported for all outcomes where sufficient studies were available. The τ 2 estimate and I 2 statistic were used as tests for heterogeneity and a funnel plot with the Egger regression-based test was used to evaluate for publication bias. Results : From 377 identified publications, 12 were included in the analysis. In all 12 studies, the type of bariatric surgery was Roux-en-Y gastric bypass (RYGB). Comparing in iduals with and without post-bariatric surgery hypoglycaemia following an ingested nutrient load, the standardised mean difference in peak GLP-1 was 0.57 (95% CI, 0.32, 0.82), peak GIP 0.05 (-0.26, 0.36), peak insulin 0.84 (0.44, 1.23), peak C-peptide 0.69 (0.28, 1.1) and peak glucagon 0.05 (-0.26, 0.36). HbA 1c was less in in iduals with hypoglycaemia − 0.40 (-0.67, -0.12). There was no evidence of substantial heterogeneity in any outcome except for peak insulin: τ 2 = 0.2, I 2 = 54.3. No publication bias was evident. Conclusion : Following RYGB, postprandial peak plasma GLP-1, insulin and C-peptide concentrations are greater in in iduals with post-bariatric surgery hypoglycaemia, while HbA 1c is less. These observations support the concept that antagonism of GLP-1 would prove beneficial in the management of in iduals with hypoglycaemia following RYGB. PROSPERO Registration Number: CRD42021287515.
Publisher: Elsevier BV
Date: 07-2023
Publisher: American Diabetes Association
Date: 10-05-2014
DOI: 10.2337/DC13-1813
Abstract: Exogenous GLP-1 slows gastric emptying in health and diabetes leading to diminished glycemic excursions. Gastric emptying is markedly accelerated by hypoglycemia. The primary objective was to determine whether GLP-1 attenuates the acceleration of gastric emptying induced by hypoglycemia. Ten healthy volunteers were studied on four separate days in a randomized double-blind fashion. Blood glucose was stabilized using a glucose/insulin cl at hypoglycemia (2.6 mmol/L on two occasions [hypo]) or euglycemia (6.0 mmol/L on two occasions [eu]) between T = −15 and 45 min before cl ing at 6.0 mmol/L until 180 min. During hypoglycemia and euglycemia, subjects received intravenous GLP-1 (1.2 pmol/kg/min) or placebo. At T = 0 min, subjects ingested 100 g beef mince labeled with 20 MBq 99mTc-sulfur-colloid and 3 g of 3-O-methyl-glucose (3-OMG), a marker of glucose absorption. Gastric emptying was measured scintigraphically from T = 0 to 180 min and serum 3-OMG taken at 15-min intervals. The areas under the curve for gastric emptying and 3-OMG concentration were analyzed using one-way repeated-measures ANOVA with Bonferroni-Holm adjusted post hoc tests. Gastric emptying was accelerated during hypoglycemia (hypo lacebo vs. eu lacebo P & 0.001), as was glucose absorption (P & 0.03). GLP-1 slowed emptying during euglycemia (eu lacebo vs. eu/GLP-1 P & 0.001). However, hypoglycemia-induced acceleration of gastric emptying on placebo was markedly diminished by GLP-1 (hypo lacebo vs. hypo/GLP-1 P & 0.008), as was glucose absorption (P & 0.01). Acute administration of exogenous GLP-1 attenuates, but does not abolish, the acceleration of gastric emptying by insulin-induced hypoglycemia in healthy subjects.
Publisher: Springer Science and Business Media LLC
Date: 23-01-2018
Publisher: MDPI AG
Date: 23-06-2022
DOI: 10.3390/NU14132603
Abstract: Background: To evaluate the methodological quality of (1) clinical practice guidelines (CPGs) that inform nutrition care in critically ill adults using the AGREE II tool and (2) CPG recommendations for determining energy expenditure using the AGREE-REX tool. Methods: CPGs by a professional society or academic group, intended to guide nutrition care in critically ill adults, that used a systematic literature search and rated the evidence were included. Four databases and grey literature were searched from January 2011 to 19 January 2022. Five investigators assessed the methodological quality of CPGs and recommendations specific to energy expenditure determination. Scaled domain scores were calculated for AGREE II and a scaled total score for AGREE-REX. Data are presented as medians (interquartile range). Results: Eleven CPGs were included. Highest scoring domains for AGREE II were clarity of presentation (82% [76–87%]) and scope and purpose (78% [66–83%]). Lowest scoring domains were applicability (37% [32–42%]) and stakeholder involvement (46% [33–51%]). Eight (73%) CPGs provided recommendations relating to energy expenditure determination scores were low overall (37% [36–40%]) and across in idual domains. Conclusions: Nutrition CPGs for critically ill patients are developed using systematic methods but lack engagement with key stakeholders and guidance to support application. The quality of energy expenditure determination recommendations is low.
Publisher: Springer Science and Business Media LLC
Date: 06-06-2015
DOI: 10.1007/S00125-015-3638-0
Abstract: A postprandial fall in BP occurs frequently in older in iduals and in patients with type 2 diabetes. The magnitude of this decrease in BP is related to the rate of gastric emptying (GE). Intravenous administration of glucagon-like peptide-1 (GLP-1) attenuates the hypotensive response to intraduodenal glucose in healthy older in iduals. We sought to determine the effects of exogenous GLP-1 on BP, GE, superior mesenteric artery (SMA) flow and glycaemic response to oral ingestion of glucose in healthy older in iduals and patients with type 2 diabetes. Fourteen older volunteers (six men, eight women age 72.1 ± 1.1 years) and ten patients with type 2 diabetes (six men, four women age 68.7 ± 3.4 years HbA1c 6.6 ± 0.2% [48.5 ± 2.0 mmol/mol] nine with blood glucose managed with metformin, two with a sulfonylurea and one with a dipeptidyl-peptidase 4 inhibitor) received an i.v. infusion of GLP-1 (0.9 pmol kg(-1) min(-1)) or saline (154 mmol/l NaCl) for 150 min (t = -30 min to t = 120 min) in randomised order. At t = 0 min, volunteers consumed a radiolabelled 75 g glucose drink. BP was assessed with an automated device, GE by scintigraphy and SMA flow by ultrasonography. Blood glucose and serum insulin were measured. GLP-1 attenuated the fall in diastolic BP after the glucose drink in older in iduals (p < 0.05) and attenuated the fall in systolic and diastolic BP in patients with type 2 diabetes (p < 0.05). GE was faster in patients with type 2 diabetes than in healthy in iduals (p < 0.05). In both groups, in iduals had slower GE (p < 0.001), decreased SMA flow (p < 0.05) and a lower degree of glycaemia (p < 0.001) when receiving GLP-1. Intravenous GLP-1 attenuates the hypotensive response to orally administered glucose and decreases SMA flow, probably by slowing GE. GLP-1 and 'short-acting' GLP-1 agonists may be useful in the management of postprandial hypotension.
Publisher: The Endocrine Society
Date: 26-07-2017
Publisher: Elsevier BV
Date: 09-2019
DOI: 10.1016/J.AUCC.2018.09.001
Abstract: Approximately 9000 patients with type-2 diabetes mellitus (T2DM) are admitted to an intensive care unit (ICU) in Australia and New Zealand annually. For these patients, recent exploratory data suggest that targeting a more liberal blood glucose range during ICU admission may be safe and potentially beneficial. However, the current approach to blood glucose management of patients with T2DM in Australia and New Zealand ICUs is not well described, and there is uncertainty about clinician equipoise for trials of liberal glycaemic control in these patients. The aim is to describe self-reported blood glucose management in patients with T2DM by intensivists working in Australian and New Zealand ICUs and to establish whether equipoise exists for a trial of liberal versus standard glycaemic control in such patients. An online questionnaire of Australia and New Zealand intensivists conducted in July-September 2016. Seventy-one intensivists responded. Forty-five (63%) used a basic nomogram to titrate insulin. Sixty-six (93%) reported that insulin was commenced at blood glucose concentrations >10 mmol/L and titrated to achieve a blood glucose concentration between 6.0 and 10.0 mmol/L. A majority of respondents (75%) indicated that there was insufficient evidence to define optimal blood glucose targets in patients with T2DM, and 59 (83%) were prepared to enrol such patients in a clinical trial to evaluate a more liberal approach. A majority of respondents were uncertain about the optimal blood glucose target range for patients with T2DM and would enrol such patients in a comparative trial of conventional versus liberal blood glucose control.
Publisher: Wiley
Date: 12-12-2018
Abstract: Nutrition delivered to patients with a traumatic brain injury (TBI) is typically below prescribed amounts. While the dietitian plays an important role in the assessment and provision of nutrition needs, they are part of a multidisciplinary team. The views and attitudes of medical and nursing practitioners are likely to be crucial to implementation of nutrition to patients with TBI, but there is limited information describing these. A qualitative exploratory approach was used to explore the views and attitudes of medical and nursing practitioners on nutrition for patients with TBI. Participants at 2 major neurotrauma hospitals in Australia completed in idual semi-structured interviews with a set of questions and a case study. Interviews were transcribed and coded for themes. Thirty-four health practitioners participated: 18 nurses and 16 physicians. Three major themes emerged: (1) nutrition practices over the hospital admission reflect the recovery course, (2) there are competing priorities when caring for patients with TBI, and (3) the implementation of nutrition therapy is influenced by practitioner roles and expectations. Use of qualitative inquiry in the study of attitudes toward nutrition provision to patients with TBI provided detailed insights into the challenges of operationalizing nutrition therapy. These insights can be used to clarify communication between health practitioners working with patients with TBI across the continuum of care.
Publisher: Springer Science and Business Media LLC
Date: 06-02-2017
Publisher: Springer Science and Business Media LLC
Date: 04-12-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2014
Publisher: Springer Science and Business Media LLC
Date: 19-06-2015
Publisher: Wiley
Date: 28-01-2020
DOI: 10.1002/JPEN.1732
Publisher: Springer Science and Business Media LLC
Date: 25-10-2013
DOI: 10.1007/S00134-012-2719-5
Abstract: To compare nutrient-stimulated changes in superior mesenteric artery (SMA) blood flow, glucose absorption and glycaemia in in iduals older than 65 years with, and without, critical illness. Following a 1-h 'observation' period (t (0)-t (60)), 0.9 % saline and glucose (1 kcal/ml) were infused directly into the small intestine at 2 ml/min between t (60)-t (120), and t (120)-t (180), respectively. SMA blood flow was measured using Doppler ultrasonography at t (60) (fasting), t (90) and t (150) and is presented as raw values and nutrient-stimulated increment from baseline (Δ). Glucose absorption was evaluated using serum 3-O-methylglucose (3-OMG) concentrations during, and for 1 h after, the glucose infusion (i.e. t (120)-t (180) and t (120)-t (240)). Mean arterial pressure was recorded between t (60)-t (240). Data are presented as median (25th, 75th percentile). Eleven mechanically ventilated critically ill patients [age 75 (69, 79) years] and nine healthy volunteers [70 (68, 77) years] were studied. The magnitude of the nutrient-stimulated increase in SMA flow was markedly less in the critically ill when compared with healthy subjects [Δt (150): patients 115 (-138, 367) versus health 836 (618, 1,054) ml/min P = 0.001]. In patients, glucose absorption was reduced during, and for 1 h after, the glucose infusion when compared with health [AUC(120-180): 4.571 (2.591, 6.551) versus 11.307 (8.447, 14.167) mmol/l min P < 0.001 and AUC(120-240): 26.5 (17.7, 35.3) versus 40.6 (31.7, 49.4) mmol/l min P = 0.031]. A close relationship between the nutrient-stimulated increment in SMA flow and glucose absorption was evident (3-OMG AUC(120-180) and ∆SMA flow at t (150): r (2) = 0.29 P 65 years, stimulation of SMA flow by small intestinal glucose infusion may be attenuated, which could account for the reduction in glucose absorption.
Publisher: Springer Science and Business Media LLC
Date: 20-11-2019
Publisher: Springer Science and Business Media LLC
Date: 19-01-2018
Publisher: American Association for the Advancement of Science (AAAS)
Date: 13-05-2011
Abstract: Discerning the neural correlates of (un)consciousness sheds light on the mechanisms underlying vegetative states.
Publisher: Elsevier BV
Date: 12-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1097/CCM.0000000000003092
Abstract: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. ICUs. Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo ( n = 45 and n = 60, respectively). IV angiotensin II or placebo. Primary end point: survival through day 28 secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo ( p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo ( p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo ( p = 0.001), respectively. In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
Publisher: Wiley
Date: 17-03-2014
Abstract: We aimed to determine the incidence of enteral feed intolerance and factors associated with intolerance and to assess the influence of intolerance on nutrition and clinical outcomes. We conducted a retrospective analysis of data from an international observational cohort study of nutrition practices among 167 intensive care units (ICUs). Data were collected on nutrition adequacy, ventilator-free days (VFDs), ICU stay, and 60-day mortality. Intolerance was defined as interruption of enteral nutrition (EN) due to gastrointestinal (GI) reasons (large gastric residuals, abdominal distension, emesis, diarrhea, or subjective discomfort). Logistic regression was used to determine risk factors for intolerance and their clinical significance. A sensitivity analysis restricted to sites specifying a gastric residual volume ≥200 mL to identify intolerance was also conducted. Data from 1,888 ICU patients were included. The incidence of intolerance was 30.5% and occurred after a median 3 days from EN initiation. Patients remained intolerant for a mean (±SD) duration of 1.9 ± 1.3 days . Intolerance was associated with worse nutrition adequacy vs the tolerant (56% vs 64%, P < .0001), fewer VFDs (2.5 vs 11.2, P < .0001), increased ICU stay (14.4 vs 11.3 days, P < .0001), and increased mortality (30.8% vs 26.2, P = .04). The sensitivity analysis demonstrated that intolerance remained associated with negative outcomes. Although mortality was greater among the intolerant patients, this was not statistically significant. Intolerance occurs frequently during EN in critically ill patients and is associated with poorer nutrition and clinical outcomes.
Publisher: Baishideng Publishing Group Inc.
Date: 2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-06-2023
DOI: 10.1212/WNL.0000000000207473
Abstract: Comprehensive guidelines for the diagnosis, prognosis, and treatment of disorders of consciousness (DoC) in pediatric patients have not yet been released. We aimed to summarize available evidence for DoC with days duration to support the future development of guidelines for children, adolescents and young adults aged 6 months–18 years. This scoping review was reported based on Preferred Reporting Items for Systematic reviews and Meta-Analyses–extension for Scoping Reviews guidelines. A systematic search identified records from 4 databases: PubMed, Embase, Cochrane Library, and Web of Science. Abstracts received 3 blind reviews. Corresponding full-text articles rated as “in-scope” and reporting data not published in any other retained article (i.e., no double reporting) were identified and assigned to 5 thematic evaluating teams. Full-text articles were reviewed using a double-blind standardized form. Level of evidence was graded, and summative statements were generated. On November 9, 2022, 2,167 documents had been identified 132 articles were retained, of which 33 (25%) were published over the past 5 years. Overall, 2,161 in iduals met the inclusion criteria female patients were 527 of 1,554 (33.9%) cases included, whose sex was identifiable. Of 132 articles, 57 (43.2%) were single case reports and only 5 (3.8%) clinical trials the level of evidence was prevalently low (80/132 60.6%). Most studies included neurobehavioral measures (84/127 66.1%) and neuroimaging (81/127 63.8%) 59 (46.5%) were mainly related to diagnosis, 56 (44.1%) to prognosis, and 44 (34.6%) to treatment. Most frequently used neurobehavioral tools included the Coma Recovery Scale–Revised, Coma/Near-Coma Scale, Level of Cognitive Functioning Assessment Scale, and Post-Acute Level of Consciousness scale. EEG, event-related potentials, structural CT, and MRI were the most frequently used instrumental techniques. In 29/53 (54.7%) cases, DoC improvement was observed, which was associated with treatment with amantadine. The literature on pediatric DoCs is mainly observational, and clinical details are either inconsistently presented or absent. Conclusions drawn from many studies convey insubstantial evidence and have limited validity and low potential for translation in clinical practice. Despite these limitations, our work summarizes the extant literature and constitutes a base for future guidelines related to the diagnosis, prognosis, and treatment of pediatric DoC.
Publisher: Springer Science and Business Media LLC
Date: 2012
DOI: 10.1186/CC11522
Publisher: Routledge
Date: 20-06-2017
Publisher: Springer Science and Business Media LLC
Date: 20-02-2018
Publisher: Wiley
Date: 11-02-2023
DOI: 10.5694/MJA2.51850
Publisher: American Thoracic Society
Date: 06-2020
Publisher: Wiley
Date: 10-06-2022
DOI: 10.1002/JPEN.2137
Publisher: Springer Science and Business Media LLC
Date: 18-09-2019
DOI: 10.1186/S13054-019-2597-0
Abstract: Metabolic alterations in the critically ill have been studied for more than a century, but the heterogeneity of the critically ill patient population, the varying duration and severity of the acute phase of illness, and the many confounding factors have hindered progress in the field. These factors may explain why management of metabolic alterations and related conditions in critically ill patients has for many years been guided by recommendations based essentially on expert opinion. Over the last decade, a number of randomized controlled trials have been conducted, providing us with important population-level evidence that refutes several longstanding paradigms. However, between-patient variation means there is still substantial uncertainty when translating population-level evidence to in iduals. A cornerstone of metabolic care is nutrition, for which there is a multifold of published guidelines that agree on many issues but disagree on others. Using a series of nine questions, we provide a review of the latest data in this field and a background to promote efforts to address the need for international consistency in recommendations related to the metabolic care of the critically ill patient. Our purpose is not to replace existing guidelines, but to comment on differences and add perspective.
Publisher: Wiley
Date: 27-04-2018
DOI: 10.1002/JPEN.1166
Abstract: International guidelines recommend greater protein delivery to critically ill patients than they currently receive. This pilot randomized clinical trial aimed to determine whether a volume-target enteral protocol with supplemental protein delivered greater amounts of protein and energy to critically ill patients compared with standard care. Sixty participants received either the intervention (volume-based protocol, with protein supplementation) or standard nutrition care (hourly-rate-based protocol, without protein supplementation) in the intensive care unit (ICU). Coprimary outcomes were average daily protein and energy delivery. Secondary outcomes included change in quadriceps muscle layer thickness (QMLT, ultrasound) and malnutrition (subjective global assessment) at ICU discharge. Mean (SD) protein and energy delivery per day from nutrition therapy for the intervention were 1.2 (0.30) g/kg and 21 (5.2) kcal/kg compared with 0.75 (0.11) g/kg and 18 (2.7) kcal/kg for standard care. The mean difference between groups in protein and energy delivery per day was 0.45 g/kg (95% CI, 0.33-0.56 P < .001) and 2.8 kcal/kg (95% CI, 0.67-4.9, P = .01). Muscle loss (QMLT) at discharge was attenuated by 0.22 cm (95% CI, 0.06-0.38, P = .01) in patients receiving the intervention compared with standard care. The number of malnourished patients was fewer in the intervention [2 (7%) vs 8 (28%) P = .04]. Mortality and duration of admission were similar between groups. A high-protein volume-based protocol with protein supplementation delivered greater amounts of protein and energy. This intervention was associated with attenuation of QMLT loss and reduced prevalence of malnutrition at ICU discharge.
Publisher: Springer Science and Business Media LLC
Date: 2014
DOI: 10.1186/CC13780
Publisher: Springer Science and Business Media LLC
Date: 14-11-2018
Publisher: Elsevier BV
Date: 11-2019
DOI: 10.1016/J.AUCC.2018.11.064
Abstract: Critically ill patients with type 2 diabetes mellitus (T2DM) and chronic hyperglycaemia may benefit from a more liberal approach to glucose control than patients with previously normal glucose tolerance. It may therefore be useful to rapidly determine HbA1c concentrations. Point-of-care (POC) analysers offer rapid results but may be less accurate than laboratory analysis. The aim of this study was to determine agreement between POC and laboratory HbA1c testing in critically ill patients with T2DM. Critically ill patients with T2DM had concurrent laboratory, capillary-, and arterial-POC HbA1c measurements performed. Data are presented as mean (standard deviation) or median [interquartile range]. Measurement agreement was assessed by Lin's concordance correlation coefficient, Bland-Altman 95% limits of agreement, and classification by Cohen's kappa statistic. HbA1c analysis was performed for 26 patients. The time to obtain a result from POC analysis took a median of 9 [7, 10] minutes. Laboratory analysis took a median of 328 [257, 522] minutes from the time of test request to the time of report. Lin's correlation coefficient showed almost perfect agreement (0.99%) for arterial- vs capillary-POC and both POC methods vs arterial laboratory analysis. Bland-Altman plots showed a mean difference of 2.0 (3.7) with 95% limits of agreement of -5.4 to 9.3 for capillary vs laboratory, 1.6 (3.4) and -5.1 to 8.4 for arterial vs laboratory, and -0.137 (2.6) and -5.2 to 4.9 for capillary vs arterial. Patient classification as having inadequately controlled diabetes (>53 mmol/mol) showed 100% agreement across all tests. HbA1c values can be accurately and rapidly obtained using POC testing in the critically ill.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1097/CCM.0000000000003087
Abstract: To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes. Prospective, open-label, sequential period study. A 22-bed mixed ICU of a tertiary hospital in Australia. We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control. Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10–14 mmol/L [180–252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6–10 mmol/L [108–180 mg/dL]). We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7–12.0 mmol/L] 198 mg/dL [157–216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5–11.0 mmol/L] 173 mg/dL [153–198 mg/dL] p 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU ( p 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively ( p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively ( p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30. In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000216516).
Publisher: Oxford University Press (OUP)
Date: 22-11-2007
DOI: 10.1093/JAC/DKM419
Publisher: Wiley
Date: 15-10-2019
DOI: 10.1002/JPEN.1725
Abstract: International guidelines recommend that protein be administered enterally to critically ill patients at doses between 1.2 and 2 g/kg per day Observational data indicate that patients frequently receive less protein. The aim of this systematic review was to evaluate patient-centered outcomes with guideline-recommended enteral protein compared with usual care. A systematic review was performed of randomized controlled trials including critically ill adult patients provided predominately enteral nutrition with mean protein at ≥1.2 g/kg per day (intervention) and <1.2 g/kg per day (comparator). Random-effects models were applied for outcomes reported in ≥3 trials. Of 1375 abstracts, 69 full-text articles were reviewed, and 6 trials meet the inclusion criteria, including 511 patients. The intervention group received a mean (SD) of 1.3 (0.08) g/kg per day, and the comparator group received 0.75 (0.15) g/kg per day protein. Insufficient data were available for meta-analyses on the primary outcome (muscle mass or strength). According to our meta-analyses, mortality at 28 days (5 studies) (risk ratio 0.92 [95% Cl 0.63-1.35], P = .66) and the durations of intensive care unit (6 studies) and hospital admission (4 studies) were similar between the intervention and comparator, with some uncertainty due to s le sizes and heterogeneity. There are insufficient data to conclude whether protein provision within the current international guideline recommendations improves outcomes. In a limited dataset, enteral protein intakes near the lower level of current recommendations do not appear to reduce admission duration or mortality when compared with usual care in critically ill.
Publisher: Wiley
Date: 29-04-2019
DOI: 10.1111/JHN.12659
Abstract: Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48 h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C) (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SS score of less than 48/60. The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650) kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000 kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.4-3.3, P = 0.001] and malnutrition (OR = 1.9, 95% CI = 1.1-3.2, P = 0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3 kg 95% CI = -2.4 to -0.2, P = 0.02) and physical function scores (-0.6 points 95% CI = -0.9 to -0.3, P = 0.001). Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.
Publisher: Wiley
Date: 10-01-2014
DOI: 10.1111/AAS.12252
Abstract: In health, the hormones amylin and glucagon-like peptide-1 (GLP-1) slow gastric emptying (GE) and modulate glycaemia. The aims of this study were to determine amylin and GLP-1 concentrations in the critically ill and their relationship with GE, glucose absorption and glycaemia. In fasted critically ill and healthy subjects (n = 26 and 23 respectively), liquid nutrient, containing 100 mg (13) C-sodium octanoate and 3 g 3-O-methlyglucose (3-OMG), was administered via a nasogastric tube. Amylin, GLP-1, glucose and 3-OMG concentrations were measured in blood s les taken during fasting, and 30 min and 60 min after the 'meal'. Breath s les were taken to determine gastric emptying coefficient (GEC). Intolerance to intragastric feeding was defined as a gastric residual volume of ≥ 250 ml and/or vomiting within the 24 h prior to the study. Although GE was slower (GEC: critically ill 2.8 ± 0.9 vs. health, 3.4 ± 0.2 P = 0.002), fasting blood glucose was higher (7.0 ± 1.9 vs. 5.7 ± 0.2 mmol/l P = 0.005) and overall glucose absorption was reduced in critically ill patients (3-OMG: 9.4 ± 8.0 vs. 17.7 ± 4.9 mmol/l.60 min P < 0.001), there were no differences in fasting or postprandial amylin concentrations. Furthermore, although fasting [1.7 (0.4-7.2) vs. 0.7 (0.3-32.0) pmol/l P = 0.04] and postprandial [3.0 (0.4-8.5) vs. 0.8 (0.4-34.3) pmol/l P = 0.02] GLP-1 concentrations were increased in the critically ill and were greater in feed intolerant when compared with those tolerating feed [3.7 (0.4-7.2) vs. 1.2 (0.7-4.6) pmol/l P = 0.02], there were no relationships between GE and fasting amylin or GLP-1 concentrations. In the critically ill, fasting GLP-1, but not amylin, concentrations are elevated and associated with feed intolerance. Neither amylin nor GLP-1 appears to substantially influence the rate of GE.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/CCM.0000000000001742
Abstract: To assess the feasibility, safety, and impact on relative hypoglycemia of liberal versus conventional blood glucose concentration targets in critically ill diabetic patients. Prospective, open-label, sequential-period exploratory study. A 22-bed multidisciplinary ICU of a tertiary care hospital in Australia. Eighty adult diabetic patients, 40 from the conventional before period and 40 from the liberal after period. Blood glucose concentration targets were 6–10 mmol/L during the before period and 10–14 mmol/L during the after period. We used admission glycated hemoglobin to estimate premorbid baseline blood glucose concentration. We defined glycemic distance as the difference between blood glucose concentration in ICU and baseline blood glucose concentration. During the first 48 ICU hours, we recorded absolute (blood glucose concentration, 3.9 mmol/L) and relative (glycemic distance, 30% below baseline) hypoglycemia rates, insulin administration, and outcomes. The groups had similar baseline characteristics. We observed a negative glycemic distance in 248 of 488 blood glucose concentrations (50.8%) during the before period and 164 of 485 (33.8%) during the after period ( p 0.001). We detected relative hypoglycemia in 20 (50.0%) and nine (22.5%) patients in the before and after periods, respectively ( p = 0.01). On day 1, 50.0% and 16.7% received insulin in the before and after periods ( p = 0.007). ICU and hospital length of stay and mortality were similar between groups. In a safety cohort of critically ill diabetic patients, a blood glucose concentration target of 10–14 mmol/L resulted in fewer episodes of negative glycemic distance or relative hypoglycemia and reduced insulin administration compared with a target of 6–10 mmol/L.
Publisher: Wiley
Date: 02-12-2019
DOI: 10.1111/JHN.12719
Abstract: Functional recovery is an important outcome for those who survive critical illness. The present study aimed to assess nutrition provision and nutrition-related outcomes in a multi-trauma cohort following intensive care unit (ICU) discharge. The present study investigated a prospective cohort of patients discharged from an ICU, who had been admitted because of major trauma and required mechanical ventilation for at least 48 h. Nutrition-related outcomes, including body weight, quadriceps muscle layer thickness (QMLT), handgrip strength and subjective global assessment, were recorded on ICU discharge, days 5-7 post-ICU discharge and then weekly until hospital discharge. Nutrition intake was recorded for 5 days post-ICU discharge. Unless otherwise stated, data are presented as the mean (SD). Twenty-eight patients [75% males, 55 (22.5) years] were included. Intake met 64% (28%) of estimated energy and 72% (32%) of protein requirements over the 5 days post-ICU discharge, which was similar to over the ICU admission. From ICU admission to hospital discharge, the mean reduction in weight was 4.2 kg (95% confidence interval = 2.2-6.3, P < 0.001) and after ICU discharge, the mean reduction in weight and QMLT was 2.6 kg (95% confidence interval = 1.0-4.2, P = 0.004) and 0.23 cm (95% confidence interval = 0.06-0.4, P = 0.01), respectively. Patients received less energy and protein than estimated requirements after ICU discharge. Weight loss and reduction in QMLT also occurred during this period.
Publisher: American Thoracic Society
Date: 04-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2019
Publisher: Elsevier BV
Date: 07-2021
Publisher: American Diabetes Association
Date: 14-09-2013
DOI: 10.2337/DC13-0307
Abstract: Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) have additive insulinotropic effects when coadministered in health. We aimed to determine whether GIP confers additional glucose lowering to that of GLP-1 in the critically ill. Twenty mechanically ventilated critically ill patients without known diabetes were studied in a prospective, randomized, double-blind, crossover fashion on 2 consecutive days. Between T0 and T420 minutes, GLP-1 (1.2 pmol/kg · min−1) was infused intravenously with either GIP (2 pmol/kg · min−1) or 0.9% saline. Between T60 and T420 minutes, nutrient liquid was infused into the small intestine at 1.5 kcal/min. Adding GIP did not alter blood glucose or insulin responses to small intestinal nutrient. GIP increased glucagon concentrations slightly before nutrient delivery (P = 0.03), but not thereafter. The addition of GIP to GLP-1 does not result in additional glucose-lowering or insulinotropic effects in critically ill patients with acute-onset hyperglycemia.
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.CLNESP.2019.02.013
Abstract: Enteral nutrition is a source of carbohydrate that may exacerbate hyperglycaemia. Its treatment, insulin, potentially exacerbates glycaemic variability. This was a prospective, parallel group, blinded, randomised feasibility trial. Patients were eligible if 18 years or over when admitted to the intensive care unit and receiving enteral nutrition (EN) exclusively with two consecutive blood glucose > 10 mmol/L. A standardized glucose management protocol determined administration of insulin. Key outcome measures were insulin administered and glycaemic variability (coefficient of variation) over the first 48 h. 41 patients were randomized to either standard EN (14.1 g/100 mL carbohydrate n = 20) or intervention EN (7.4 g/100 mL carbohydrate n = 21). Overall 59% were male, mean (±SD) age of 62.3 years ± 10.4, APACHE II score of 16.5 ± 7.8 and a median (IQR) Body Mass Index 29.0 kg/m A low carbohydrate formula was associated with reduced insulin use and glycaemic variability in enterally-fed critically ill patients with hyperglycaemia. Further large trials are required to determine the impact of this formula on clinical outcomes. Registered under Australian and New Zealand Clinical Trials Registry, ANZCTR number: 12614000166673.
Publisher: American Thoracic Society
Date: 15-09-2022
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-06-2019
DOI: 10.1002/HEP.30629
Abstract: Critical illness is associated with a disturbed regulation of gastrointestinal hormones resulting in functional and metabolic anomalies. Fibroblast growth factor 19 (FGF19) is an ileum‐derived metabolic hormone induced by bile salts upon gallbladder emptying after enteral nutrient stimulation. Our aim was to study the nutrient‐stimulated FGF19 response in 24 patients admitted to the intensive care unit (ICU) compared with 12 healthy controls. All subjects received intraduodenal high‐lipid nutrient infusion for 120 minutes. Blood was collected every 30 minutes until 1 hour after infusion, and gallbladder emptying was studied by ultrasound. Serum levels of bile salts and FGF19 were assessed. ICU patients had significantly higher fasting bile salt serum levels compared with controls, whereas FGF19 serum levels were similar. In both groups, nutrient infusion elicited substantial bile salt elevations ( P 0.001), peaking at 90 minutes, albeit with a significantly lower peak in the ICU patients ( P = 0.029). In controls, FGF19 was significantly elevated relative to baseline from 120 minutes onward ( P 0.001). In ICU patients, the FGF19 response was blunted, as reflected by significantly lower FGF19 elevations at 120, 150, and 180 minutes ( P 0.05) and significantly lower area under the curve (AUC) values compared with controls ( P 0.001). Gallbladder dysmotility was associated with the impaired FGF19 response in critical illness. The gallbladder ejection fraction correlated positively with FGF19 AUC values (ρ = +0.34, P = 0.045). In 10 of 24 ICU patients, gallbladder emptying was disturbed. These patients had significantly lower FGF19 AUC values ( P 0.001). Gallbladder emptying and the FGF19 response were respectively disturbed or absent in patients receiving norepinephrine. Conclusion: The nutrient‐stimulated FGF19 response is impaired in ICU patients, which is mechanistically linked to gallbladder dysmotility in critical illness. This may contribute to disturbed liver metabolism in these patients and has potential as a nutritional biomarker.
Publisher: Wiley
Date: 03-02-2020
DOI: 10.1111/NMO.13784
Abstract: Ulimorelin, a small molecule ghrelin agonist and prokinetic agent, was effective in animal models of gastroparesis and delayed transit. However, employing once daily administration, it failed in clinical trials of postoperative ileus (POI), a condition in which colonic motility recovers last. The aim of this study was to evaluate drug dosing and regional differences in drug activity between stomach and colon. Gastric emptying was assessed by scintigraphy in healthy adults at single doses of 600‐1200 µg kg −1 and multiple doses of 80‐600 µg kg −1 Q8H for 7 days. Colonic motility was assessed by 7‐region scintigraphic analysis at a dose of 600 µg kg −1 for 2 days. The primary endpoints were percent change in time to 50% (∆ t 50 ) liquid gastric emptying on Days 1, 4, and 6 and the geometric mean center of colonic transit at 24 hours (GC 24 ). Plasma concentrations of free and total ulimorelin were measured for pharmacokinetic and exposure‐response modeling. Ulimorelin 150‐600 µg kg −1 every 8 hours resulted in statistically significant improvements (∆ t 50 = 23% to 46% ( P .05)) in gastric emptying from baseline that were sustained through Day 6. However, no effects on GC 24 were observed. Pharmacokinetic analyses suggested that the free concentrations of ulimorelin achieved in POI trials and dosing frequency may have been inadequate. Ulimorelin is a potent gastric prokinetic but lacks evidence of activity in the human colon, pointing to the stomach as the predominant site of action of ghrelin in humans ClinicalTrials.gov NCT02993055.
Publisher: Annals of Laboratory Medicine
Date: 07-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2020
Publisher: Springer Science and Business Media LLC
Date: 2010
DOI: 10.1186/CC9281
Publisher: Wiley
Date: 11-03-2014
DOI: 10.1111/AAS.12302
Abstract: Clinicians and researchers frequently use the phrase 'feeding intolerance' (FI) as a descriptive term in enterally fed critically ill patients. We aimed to: (1) determine what is the most accepted definition of FI (2) estimate the prevalence of FI and (3) evaluate whether FI is associated with important outcomes. Systematic searches of peer-reviewed publications using PubMed, MEDLINE, and Web of Science were performed with studies reporting FI extracted. We identified 72 studies defining FI. In 33 studies, the definition was based on large gastric residual volumes (GRVs) together with other gastrointestinal symptoms, while 30 studies relied solely on large GRVs, six studies used inadequate delivery of enteral nutrition (EN) as a threshold, and three studies gastrointestinal symptoms without reference to GRV. The median volume used to define a 'large' GRV was 250 ml (ranges from 75 to 500 ml). The pooled proportion (n = 31 studies) of FI was 38.3% (95% CI 30.7-46.2). Five studies reported outcomes, all of them observed adverse outcome in FI patients. In three studies, respectively, FI was associated with increased mortality and ICU length-of-stay. In summary, FI is inconsistently defined but appears to occur frequently. There are preliminary data indicating that FI is associated with adverse outcomes. A standard definition of FI is required to determine the accuracy of these preliminary data.
Publisher: AMPCo
Date: 04-2013
DOI: 10.5694/MJA12.11354
Publisher: Wiley
Date: 18-03-2019
DOI: 10.1111/AAS.13354
Abstract: Critically ill patients with diabetes mellitus (DM) are at increased risk of in-hospital complications and the optimal glycemic target for such patients remains unclear. A more liberal approach to glucose control has recently been suggested for patients with DM, but uncertainty remains regarding its impact on complications. We aimed to test the hypothesis that complications would be more common with a liberal glycemic target in ICU patients with DM. Thus, we compared hospital-acquired complications in the first 400 critically ill patients with DM included in a sequential before-and-after trial of liberal (glucose target: 10-14 mmol/L) vs conventional (glucose target: 6-10 mmol/L) glucose control. Of the 400 patients studied, 165 (82.5%) patients in the liberal and 177 (88.5%) in the conventional-control group were coded for at least one hospital-acquired complication (P = 0.09). When comparing clinically relevant complications diagnosed between ICU admission and hospital discharge, we found no difference in the odds for infectious (adjusted odds ratio [aOR] for liberal-control: 1.15 [95% CI: 0.68-1.96], P = 0.60), cardiovascular (aOR 1.40 [95% CI: 0.63-3.12], P = 0.41) or neurological complications (aOR: 1.07 [95% CI: 0.61-1.86], P = 0.81), acute kidney injury (aOR 0.83 [95% CI: 0.43-1.58], P = 0.56) or hospital mortality (aOR: 1.09 [95% CI: 0.59-2.02], P = 0.77) between the liberal and the conventional-control group. In this prospective before-and-after study, liberal glucose control was not associated with an increased risk of hospital-acquired infectious, cardiovascular, renal or neurological complications in critically ill patients with diabetes.
Publisher: The Endocrine Society
Date: 2010
DOI: 10.1210/JC.2009-1503
Abstract: The role of glucagon-like peptide-1 (GLP-1) in the regulation of gastric emptying is uncertain. The aim of this study was to determine the effects of endogenous GLP-1 on gastric emptying, glucose absorption, and glycemia in health. Ten healthy fasted subjects (eight males, two females 48 +/- 7 yr) received the specific GLP-1 antagonist, exendin(9-39) amide [ex(9-39)NH(2)] (300 pmol/kg x min iv), or placebo, between -30 and 180 min in a randomized, double-blind, crossover fashion. At 0 min, a mashed potato meal ( approximately 2600 kJ) containing 3 g 3-ortho-methyl-D-glucose (3-OMG) and labeled with 20 MBq (99m)Technetium-sulphur colloid was eaten. Gastric emptying, including the time taken for 50% of the meal to empty from the stomach (T50), blood glucose, plasma 3-OMG, and plasma insulin were measured. Ex(9-39)NH(2) accelerated gastric emptying [T50 ex(9-39)NH(2), 68 +/- 8 min, vs. placebo, 83 +/- 7 min P < 0.001] and increased the overall glycemic response to the meal [area under the curve (0-180 min) ex(9-39)NH(2), 1540 +/- 106 mmol/liter x min, vs. placebo, 1388 +/- 90 mmol/liter x min P < 0.02]. At 60 min, ex(9-39)NH(2) increased the rise in glycemia [ex(9-39)NH(2), 9.9 +/- 0.5 mmol/liter, vs. placebo, 8.4 +/- 0.5 mmol/liter P < 0.01], plasma 3-OMG [ex(9-39)NH(2), 0.25 +/- 0.01 mmol/liter, vs. placebo, 0.21 +/- 0.01 mmol/liter P < 0.05], and plasma insulin [ex(9-39)NH(2), 82 +/- 13 mU/liter, vs. placebo, 59 +/- 9 mU/liter P < 0.05] concentrations. There was a close within-subject correlation between glycemia and gastric emptying [e.g. at 60 min, the increment in blood glucose and gastric emptying (T50) r = -0.89 P < 0.001]. GLP-1 plays a physiological role to slow gastric emptying in health, which impacts on glucose absorption and, hence, postprandial glycemia.
Publisher: American Diabetes Association
Date: 06-04-2017
DOI: 10.2337/DB17-0058
Abstract: Intestinal glucose stimulates secretion of the incretin hormone glucagon-like peptide 1 (GLP-1). The mechanisms underlying this pathway have not been fully investigated in humans. In this study, we showed that a 30-min intraduodenal glucose infusion activated half of all duodenal L cells in humans. This infusion was sufficient to increase plasma GLP-1 levels. With an ex vivo model using human gut tissue specimens, we showed a dose-responsive GLP-1 secretion in the ileum at ≥200 mmol/L glucose. In ex vivo tissue from the duodenum and ileum, but not the colon, 300 mmol/L glucose potently stimulated GLP-1 release. In the ileum, this response was independent of osmotic influences and required delivery of glucose via GLUT2 and mitochondrial metabolism. The requirement of voltage-gated Na+ and Ca2+ channel activation indicates that membrane depolarization occurs. KATP channels do not drive this, as tolbutamide did not trigger release. The sodium–glucose cotransporter 1 (SGLT1) substrate α-MG induced secretion, and the response was blocked by the SGLT1 inhibitor phlorizin or by replacement of extracellular Na+ with N-methyl-d-glucamine. This is the first report of the mechanisms underlying glucose-induced GLP-1 secretion from human small intestine. Our findings demonstrate a dominant role of SGLT1 in controlling glucose-stimulated GLP-1 release in human ileal L cells.
Publisher: Elsevier BV
Date: 08-2021
DOI: 10.1016/J.CLNU.2021.07.024
Abstract: Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group. This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified. Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days P = 0.37, and deaths 9 (21 %) vs. 5 (11 %) P = 0.25). In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes. Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).
Publisher: American Association for the Advancement of Science (AAAS)
Date: 02-12-2011
Abstract: King et al . raise some technical issues about our recent study showing impaired top-down processes in the vegetative state. We welcome the opportunity to provide more details about our methods and results and to resolve their concerns. We substantiate our interpretation of the results and provide a point-by-point response to the issues raised.
Publisher: Springer Science and Business Media LLC
Date: 30-01-2016
DOI: 10.1007/S00125-016-3878-7
Abstract: In healthy in iduals, both insulin and glucagon-like peptide 1 (GLP-1) are secreted in a pulsatile fashion. Insulin has greater glucose-lowering properties when administered in pulses compared with a constant i.v. infusion. The primary aim of this randomised double-dummy cross-over study was to compare the insulinotropic response to pulsatile and continuous i.v. infusions of equivalent doses of GLP-1. Twelve healthy participants aged 18-35 years were randomised to three different treatments on separate days: a continuous infusion day (GLP-1 at 0.6 pmol kg(-1) min(-1) [1 ml/min] and a 1 ml placebo bolus every 6 min) a pulsatile infusion day (placebo at 1 ml/min and a 3.6 pmol/kg GLP-1 bolus every 6 min) and a placebo day (placebo at 1 ml/min and a 1 ml placebo bolus every 6 min). Between 45 and 120 min, a hyperglycaemic cl was used to maintain blood glucose at 9 mmol/l. Venous blood glucose and plasma insulin concentrations were measured every 5 min from 0 to 45 min and every 1 min from 45 to 120 min plasma glucagon was measured every 15 min. The order of treatment was randomised by the Pharmacy Department and both study investigators and participants were blinded to the treatment arm. The dextrose requirement and glucagon data were analysed using repeated measures ANOVA and insulin data were analysed with a linear mixed effects maximum likelihood model. Continuous and pulsatile infusions of GLP-1 increased the dextrose requirement by ~threefold (p < 0.001) and increased insulin secretion by ~ninefold (p < 0.001). There was no difference in the effect of both treatments. Although hyperglycaemia reduced plasma glucagon concentrations, there was no difference between the treatment days. In healthy in iduals, pulsatile and continuous administration of i.v. GLP-1 appears to have comparable insulinotropic effects. ACTRN12612001040853 FUNDING: This study was supported by the National Health and Medical Research Council (NHMRC) of Australia.
Publisher: Elsevier BV
Date: 06-2021
DOI: 10.51893/2021.2.SR1
Abstract: BACKGROUND: Persistent psychological distress occurs frequently in family members of patients who die in an intensive care unit (ICU). OBJECTIVE: To determine the effectiveness of bereavement interventions in reducing persisting psychological distress in bereaved family members after death in an adult ICU. DESIGN: Systematic review and meta-analysis of studies that assessed the effect of bereavement interventions on persisting psychological distress in bereaved family members of ICU patients. DATA SOURCES: MEDLINE and APA Psycinfo databases were searched until April 2020. REVIEW METHODS: Two of us independently screened titles and abstracts of identified studies, and then completed full text evaluation of selected studies. We assessed risk of bias using version 2 of the Cochrane risk-of-bias tool for randomised trials and the Newcastle-Ottawa Scale, which is designed to assess the quality of non-randomised studies in meta-analyses. We also used random effects meta-analysis to assess the effect of various interventions on total Hospital Anxiety and Depression Scale (HADS) scores. RESULTS: From 664 citations, five studies were included — three multicentre randomised clinical trials and two single centre observational studies. Three studies tested the intervention of written bereavement support materials and two studies used narration of family members' experiences in the ICU. All studies reported HADS scores. Scores for Impact of Event Scale, Impact of Event Scale–Revised and Inventory of Complicated Grief were measured in some but not all studies. There was no effect of an intervention on HADS scores (weighted mean difference, −0.79 [95% confidence interval, −3.81 to 2.23] Ι2 = 65.8%). CONCLUSIONS: Owing to limited data, and clinical and statistical heterogeneity, there is considerable uncertainty regarding whether bereavement support strategies reduce, increase or have no effect on psychological distress in bereaved family members.
Publisher: Wiley
Date: 25-02-2013
DOI: 10.1111/DOM.12078
Abstract: Hyperglycaemia frequently occurs in the critically ill, in patients with diabetes, as well as those who were previously glucose-tolerant. The terminology 'stress hyperglycaemia' reflects the pathogenesis of the latter group, which may comprise up to 40% of critically ill patients. For comparable glucose concentrations during acute illness outcomes in stress hyperglycaemia appear to be worse than those in patients with type 2 diabetes. While several studies have evaluated the optimum glycaemic range in the critically ill, their interpretation in relation to clinical recommendations is somewhat limited, at least in part because patients with stress hyperglycaemia and known diabetes were grouped together, and the optimum glycaemic range was regarded as static, rather than dynamic, phenomenon. In addition to hyperglycaemia, there is increasing evidence that hypoglycaemia and glycaemic variability influence outcomes in the critically ill adversely. These three categories of disordered glucose metabolism can be referred to as dysglycaemia. While stress hyperglycaemia is most frequently managed by administration of short-acting insulin, guided by simple algorithms, this does not treat all dysglycaemic categories rather the use of insulin increases the risk of hypoglycaemia and may exacerbate variability. The pathogenesis of stress hyperglycaemia is complex, but hyperglucagonaemia, relative insulin deficiency and insulin resistance appear to be important. Accordingly, novel agents that have a pathophysiological rationale and treat hyperglycaemia, but do not cause hypoglycaemia and limit glycaemic variability, are appealing. The potential use of glucagon-like peptide-1 (or its agonists) and dipeptyl-peptidase-4 inhibitors is reviewed.
Publisher: Wiley
Date: 05-03-2020
DOI: 10.1002/NCP.10478
Publisher: Wiley
Date: 26-11-2021
DOI: 10.1002/NCP.10599
Publisher: Elsevier BV
Date: 10-2015
DOI: 10.1016/J.CLNU.2014.10.006
Abstract: While feeding intolerance (FI) is clinically important in the critically ill it is inconsistently defined. By evaluating definitions of FI based on relationships between symptoms and signs of gastrointestinal (GI) dysfunction and mortality the objective was to define FI using the definition that was most strongly associated with subsequent mortality. Data from all adult patients admitted to a single ICU between 2004 and 2011, and who were receiving enteral nutrition (EN), were analysed. The amount of EN administered, presence of absent bowel sounds (BS), vomiting and/or regurgitation, diarrhoea, bowel distension, and large gastric residual volumes (GRVs) were documented daily. A GRV ≥500 ml/day was considered as large and the sum of gastrointestinal (GI) symptoms including large GRV was calculated daily. Various definitions of FI were modelled. Definitions using only GRV, or GRV with other GI symptoms, or GRV and failure to reach preset EN targets were evaluated. The predictive power of FI on mortality was tested by adding the presence of FI (different definitions were tested one-by-one) into multiple regression analyses together with admission day demographic and severity of illness variables. Of the 1712 patients included, 221 (12.9%) died in ICU and 495 (28.9%) had died within 90 days after ICU admission. The definition of FI based on the presence of at least three out of five GI symptoms was most strongly related to ICU-mortality (6.3% prevalence in survivors vs. 23.5% in non-survivors, p < 0.001, odds ratio (95%CI) 3.39 (2.23-5.14)), whereas EN <23% of caloric target was the strongest predictor for mortality 90 days after admission (50.7% prevalence among survivors vs 75.2% in non-survivors, p < 0.001, odds ratio (95% CI) 2.34 (1.80-3.04)). FI is associated with increased mortality but the strength of this relationship depends on the definition used. The 'best' definition of FI for prediction of ICU-mortality is based on a complex assessment of GI symptoms (including large GRV), whereas enteral underfeeding is the definition of FI that is the strongest predictor of death within 90 days of admission. Our 'best' definitions are not immediately generalizable, but should help building up future studies.
Publisher: Elsevier BV
Date: 12-2020
DOI: 10.51893/2020.4.OA8
Abstract: Objective: To characterise the assessment and management of delirium in patients admitted to intensive care units (ICUs) in Australia and New Zealand. Methods: We conducted a multicentre observational point prevalence study across 44 adult Australian and New Zealand ICUs. Data were extracted for all patients in the ICU in terms of assessment and treatment of delirium. ICU-level data were collected regarding the use of explicit protocols related to delirium. Results: We studied 627 patients, with 54% (336/627) having at least one delirium screening assessment performed. The Confusion Assessment Method for the ICU (CAM-ICU) was the most frequently used tool (88%, 296/336). Of patients assessed, 20% (68) were identified to have delirium. Eighteen per cent (111) of patients were administered a drug to manage delirium, with 41% (46) of those receiving a drug having no recorded assessment for delirium on that day. Of the drugs used to treat delirium, quetiapine was the most frequently administered. Physical restraints were applied to 8% (48/626) of patients, but only 17% (8/48) of such patients had been diagnosed with delirium. Most physically restrained patients either did not have delirium diagnosed (31%, 15/48) or had no formal assessment recorded (52%, 25/48) on that day. Conclusions: On the study day, more than 50% of patients had a delirium screening assessment performed, with 20% of screened patients deemed to have delirium. Drugs that are prescribed to treat delirium and physical restraints were frequently used in the absence of delirium or the formal assessment for its presence.
Publisher: Wiley
Date: 07-10-2019
DOI: 10.1002/NCP.10199
Abstract: Gastrointestinal dysmotility causes delayed gastric emptying, enteral feed intolerance, and functional obstruction of the small and large intestine, the latter functional obstructions being frequently termed ileus and Ogilvie syndrome, respectively. In addition to meticulous supportive care, drug therapy may be appropriate in certain situations. There is, however, considerable variation among in iduals regarding what gastric residual volume identifies gastric dysmotility and would encourage use of a promotility drug. While the administration of either metoclopramide or erythromycin is supported by evidence it appears that, dual-drug therapy (erythromycin and metoclopramide) reduces the rate of treatment failure. There is a lack of evidence to guide drug therapy of ileus, but neither erythromycin nor metoclopramide appear to have a role. Several drugs, including ghrelin agonists, highly selective 5-hydroxytryptamine receptor agonists, and opiate antagonists are being studied in clinical trials. Neostigmine, when infused at a relatively slow rate in patients receiving continuous hemodynamic monitoring, may alleviate the need for endoscopic decompression in some patients.
Publisher: Springer Science and Business Media LLC
Date: 2013
DOI: 10.1186/CC12758
Publisher: Springer Science and Business Media LLC
Date: 07-01-2016
DOI: 10.1186/S13054-015-1177-1
Abstract: Critical illness following head injury is associated with a hypermetabolic state but there are insufficient epidemiological data describing acute nutrition delivery to this group of patients. Furthermore, there is little information describing relationships between nutrition and clinical outcomes in this population. We undertook an analysis of observational data, collected prospectively as part of International Nutrition Surveys 2007-2013, and extracted data obtained from critically ill patients with head trauma. Our objective was to describe global nutrition support practices in the first 12 days of hospital admission after head trauma, and to explore relationships between energy and protein intake and clinical outcomes. Data are presented as mean (SD), median (IQR), or percentages. Data for 1045 patients from 341 ICUs were analyzed. The age of patients was 44.5 (19.7) years, 78 % were male, and median ICU length of stay was 13.1 (IQR 7.9-21.6) days. Most patients (94 %) were enterally fed but received only 58 % of estimated energy and 53 % of estimated protein requirements. Patients from an ICU with a feeding protocol had greater energy and protein intakes (p .001, 0.002 respectively) and were more likely to survive (OR 0.65 95 % CI 0.42-0.99 p = 0.043) than those without. Energy or protein intakes were not associated with mortality. However, a greater energy and protein deficit was associated with longer times until discharge alive from both ICU and hospital (all p .001). Nutritional deficits are commonplace in critically ill head-injured patients and these deficits are associated with a delay to discharge alive.
Publisher: Elsevier BV
Date: 05-2023
Publisher: Springer Science and Business Media LLC
Date: 03-08-2016
Publisher: Elsevier BV
Date: 06-2021
DOI: 10.51893/2021.2.OA8
Abstract: OBJECTIVE: The cost of providing care in an intensive care unit (ICU) after brain death to facilitate organ donation is unknown. The objective of this study was to estimate expenditure for the care delivered in the ICU between the diagnosis of brain death and subsequent organ donation. DESIGN: Cohort study of direct and indirect costs using bottom-up and top-down microcosting techniques. SETTING: Single adult ICU in Australia. PARTICIPANTS: All patients who met criteria for brain death and proceeded to organ donation during a 13-month period between 1 January 2018 and 31 January 2019. MAIN OUTCOME MEASURES: A comprehensive cost estimate for care provided in the ICU from determination of brain death to transfer to theatre for organ donation. RESULTS: Forty-five patients with brain death became organ donors during the study period. The mean duration of post-death care in the ICU was 37.9 hours (standard deviation [SD], 16.5) at a mean total cost of $7520 (SD, $3136) per donor. ICU staff salaries were the greatest contributor to total costs, accounting for a median proportion of 0.72 of total expenditure (interquartile range, 0.68–0.75). CONCLUSIONS: Substantial costs are incurred in ICU for the provision of patient care in the interval between brain death and organ donation.
Publisher: Springer Science and Business Media LLC
Date: 2014
DOI: 10.1186/CC13961
Publisher: Wiley
Date: 20-06-2019
DOI: 10.1002/JPEN.1196
Abstract: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults. This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]). Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.
Publisher: Wiley
Date: 04-07-2018
Abstract: To determine whether the placement of a post-pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian. This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post-pyloric intubation by the dietitian. The 10 'learning' attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine 'consolidation' attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X-ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice. A total of 19 post-pyloric tube placements were attempted in 18 patients (52 (23-70) years, ICU admission diagnoses: trauma n = 4 respiratory failure n = 3 and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9-27.1 minutes). A dietitian can be trained to safely and successfully place PPFT in critically ill patients.
Publisher: Elsevier BV
Date: 11-2019
Publisher: American Diabetes Association
Date: 12-07-2016
DOI: 10.2337/DBI16-0023
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
Publisher: JMIR Publications Inc.
Date: 09-04-2018
DOI: 10.2196/RESPROT.9374
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2019
Publisher: Wiley
Date: 06-10-2017
DOI: 10.1111/JHN.12432
Abstract: Nutrition studies in patients admitted to hospital frequently disregard oral intake because measurement is time-intensive and logistically challenging. In free-living populations, weighed food records (WFR) are the gold-standard and are conducted on weekend and weekdays to capture variations in intake, although this may not translate during hospitalisation. The present study aimed to determine whether oral intake differs between weekends and weekdays in hospitalised patients. For adult patients initially admitted to the intensive therapy unit with a moderate-severe head injury over a 12-month period, WFR were conducted each week on Tuesday, Thursday and Saturday throughout hospitalisation. Meal components were weighed before and after consumption, and energy and protein intakes were calculated using specialised software. Data are reported as the mean (SD). Differences were assessed using paired t-tests and agreement using Bland-Altman plots. Thirty-two patients had WFR collected on 220 days, 68% (n = 149) on weekdays and 32% (n = 71) on weekends. Overall, daily intakes were 5.72 (3.67) MJ [1367 (877) kcal] and 62 (40) g protein. There were no differences in intake across all days (P = 0.937 energy, P = 0.797 protein), nor between weekdays and weekends, in weeks 1-3 of oral intake (all P > 0.1). Limits of agreement between mean intakes across days were wide for energy [range -11.20 to 9.55 MJ (-2680 to 2283 kcal)] and protein (range -125 to 110 g). Grouped energy and protein intakes from WFR in hospitalised patients are similar on weekdays and weekends, although large intra-patient variations occur. Future quantification of oral intake during hospitalisation should include as many days as feasible, although not necessarily weekend days, to reflect true intake.
Publisher: Springer Science and Business Media LLC
Date: 24-02-2016
DOI: 10.1007/S12630-016-0612-3
Abstract: Stress ulcer prophylaxis (SUP) using histamine-2-receptor antagonists has been a standard of care in intensive care units (ICUs) for four decades. Proton pump inhibitors (PPIs) are increasingly used despite apparently lower background rates of gastrointestinal bleeding and growing concerns about PPI-associated complications. Our objective was to understand the views and prescribing habits amongst Canadian physicians regarding SUP in the ICU and to gauge interest in a future randomized-controlled trial (RCT). We created a short self-administered survey about SUP for critically ill adults, evaluated its clinical sensibility, and pilot tested the instrument. We surveyed all physician members of the Canadian Critical Care Trials Group (CCCTG) by e-mail and sent reminders three and five weeks later. We received 94 of 111 (85%) surveys from the validated respondent pool between May and June, 2015. Respondents reported use of SUP most commonly in patients 1) receiving invasive mechanical ventilation (62, 66%), 2) expected to be ventilated for ≥ two days (25, 27%), or 3) receiving mechanical ventilation but nil per os (NPO) (20, 21%). Stress ulcer prophylaxis is discontinued when patients no longer receive mechanical ventilation (75%), no longer are NPO (22%), or are discharged from the ICU (19%). Stress ulcer prophylaxis involves PPIs in 68% of centres. Most respondents endorsed the need for a large rigorous RCT of PPI vs placebo to understand the risks and benefits of this practice. Stress ulcer prophylaxis is reportedly used primarily for the duration of mechanical ventilation. The CCCTG physicians believe that a placebo-controlled RCT is needed to evaluate the effectiveness and safety of contemporary SUP with PPIs.
Publisher: Springer Science and Business Media LLC
Date: 2010
DOI: 10.1186/CC9039
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: Springer Science and Business Media LLC
Date: 12-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2013
Publisher: JMIR Publications Inc.
Date: 09-11-2017
Publisher: Elsevier BV
Date: 12-2017
DOI: 10.1016/J.CLNU.2017.09.026
Abstract: The amount of energy required to improve clinical outcomes in critically ill adults is unknown. The aim of this systematic review and meta-analysis was to evaluate the impact of near target energy delivery to critically ill adults on mortality and other clinically relevant outcomes. Following PRISMA guidelines, MEDLINE, EMBASE, CINHAL and the Cochrane Library were searched for randomised controlled trials evaluating nutrition interventions in adult critical care populations. Included studies compared delivery of ≥80% of predicted energy requirements (near target) from enteral and/or parenteral nutrition to <80% (standard care) and reported mortality. The quality of in idual studies was assessed using the Cochrane 'Risk of Bias' tool, and the overall body of evidence using the GRADE approach. Fixed or random effect meta-analyses were used pending the presence of heterogeneity (I Ten trials with 3155 participants were included. Mortality was unaffected by the intervention (RR 1.02, 95% CI 0.81, 1.27, p = 0.89, I The delivery of near target energy when compared to standard care in adult critically ill patients was not associated with an effect on mortality. Because the quality of the evidence across outcomes was very low there is considerable uncertainty surrounding this estimate. This has implications for clinical utility of the evidence within the included reviews.
Publisher: American Diabetes Association
Date: 11-01-2014
DOI: 10.2337/DC13-1616
Publisher: Baishideng Publishing Group Inc.
Date: 2007
Abstract: Malnutrition is associated with poor outcomes in critically ill patients. Although nutritional support is yet to be proven to improve mortality in non-malnourished critically ill patients, early enteral feeding is considered best practice. However, enteral feeding is often limited by delayed gastric emptying. The best method to clinically identify delayed gastric emptying and feed intolerance is unclear. Gastric residual volume (GRV) measured at the bedside is widely used as a surrogate marker for gastric emptying, but the value of GRV measurement has recently been disputed. While the mechanisms underlying delayed gastric emptying require further investigation, recent research has given a better appreciation of the pathophysiology. A number of pharmacological strategies are available to improve the success of feeding. Recent data suggest a combination of intravenous metoclopramide and erythromycin to be the most successful treatment, but novel drug therapies should be explored. Simpler methods to access the duodenum and more distal small bowel for feed delivery are also under investigation. This review summarises current understanding of the factors responsible for, and mechanisms underlying feed intolerance in critical illness, together with the evidence for current practices. Areas requiring further research are also highlighted.
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.BURNS.2014.09.013
Abstract: It has been proposed that nutritional therapy in critically ill patients after major burn reduces mortality. However, the actual practice of nutrient delivery, and the effect on outcome, has not been described. To evaluate international practices related to nutritional support and outcomes in mechanically ventilated patients with burn injury. Data from the International Nutrition Surveys (2007-2011) for patients with a primary diagnosis of burn were extracted and analysed. Eighty-eight of 90 patients (aged 16-84 years) received enteral nutrition. The median time for initiation of enteral feeding was 17 h [range 0-65]. Fifty patients (57%) had interruptions to nutrient delivery, most often these interruptions were fasting for operative procedures. There were substantive energy and protein deficits [943 (654) kcal/day and 49 (41) g/day, respectively mean (SD)]. Nineteen (21%) patients died within 60 days of admission, and the energy and protein deficits were greater in those that died compared with survivors [died vs. survived, energy: 1251 (742) vs. 861 (607) kcal/d p=0.02 and protein 67(42) vs. 44(39) g/d p=0.03]. Energy and protein deficits were associated with increased mortality with the greater the deficit, the stronger the association with death (odds ratio for death: energy deficit/100 kcal 1.10 (1.01, 1.19) p=0.028 and protein/10 g 1.16 (1.01, 1.33) p=0.037). Results were similar and remained significant after adjusting for severity of illness. Mechanically ventilated patients following burn develop substantial energy and protein deficits, with lesser deficits observed in survivors.
Publisher: Springer Science and Business Media LLC
Date: 2014
DOI: 10.1186/CC13737
Publisher: Springer Science and Business Media LLC
Date: 06-02-2020
DOI: 10.1186/S13054-020-2733-X
Abstract: In patients with vasodilatory shock, plasma concentrations of angiotensin I (ANG I) and II (ANG II) and their ratio may reflect differences in the response to severe vasodilation, provide novel insights into its biology, and predict clinical outcomes. The objective of these protocol prespecified and subsequent post hoc analyses was to assess the epidemiology and outcome associations of plasma ANG I and ANG II levels and their ratio in patients with catecholamine-resistant vasodilatory shock (CRVS) enrolled in the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. We measured ANG I and ANG II levels at baseline, calculated their ratio, and compared these results to values from healthy volunteers (controls). We dichotomized patients according to the median ANG I/II ratio (1.63) and compared demographics, clinical characteristics, and clinical outcomes. We constructed a Cox proportional hazards model to test the independent association of ANG I, ANG II, and their ratio with clinical outcomes. Median baseline ANG I level (253 pg/mL [interquartile range (IQR) 72.30–676.00 pg/mL] vs 42 pg/mL [IQR 30.46–87.34 pg/mL] in controls P 0.0001) and median ANG I/II ratio (1.63 [IQR 0.98–5.25] vs 0.4 [IQR 0.28–0.64] in controls P 0.0001) were elevated, whereas median ANG II levels were similar (84 pg/mL [IQR 23.85–299.50 pg/mL] vs 97 pg/mL [IQR 35.27–181.01 pg/mL] in controls P = 0.9895). At baseline, patients with a ratio above the median (≥1.63) had higher ANG I levels ( P 0.0001), lower ANG II levels ( P 0.0001), higher albumin concentrations ( P = 0.007), and greater incidence of recent (within 1 week) exposure to angiotensin-converting enzyme inhibitors ( P 0.00001), and they received a higher norepinephrine-equivalent dose ( P = 0.003). In the placebo group, a baseline ANG I/II ratio .63 was associated with improved survival (hazard ratio 0.56 95% confidence interval 0.36–0.88 P = 0.01) on unadjusted analyses. Patients with CRVS have elevated ANG I levels and ANG I/II ratios compared with healthy controls. In such patients, a high ANG I/II ratio is associated with greater norepinephrine requirements and is an independent predictor of mortality, thus providing a biological rationale for interventions aimed at its correction. ClinicalTrials.gov identifier NCT02338843 . Registered 14 January 2015.
Publisher: Elsevier BV
Date: 06-2012
Abstract: The gastrokinetic drug erythromycin is commonly administered to critically ill patients during intragastric feeding to augment small intestinal nutrient delivery. However, erythromycin has been reported to increase the prevalence of diarrhea, which may reflect reduced absorption and/or accelerated small intestinal transit. The objective was to evaluate the effects of intravenous erythromycin on small intestinal nutrient absorption and transit in the critically ill. On consecutive days, erythromycin (200 mg in 20 mL 0.9% saline) or placebo (20 mL 0.9% saline) were infused intravenously between -20 and 0 min in a randomized, blinded, crossover fashion. Between 0 and 30 min, a liquid nutrient containing 3-O-methylglucose (3-OMG), [13C]triolein, and [(99m)Tc]sulfur colloid was administered directly into the small intestine at 2 kcal/min. Serum 3-OMG concentrations and exhaled (13)CO2 (indices of glucose and lipid absorption, respectively) were measured. Cecal arrival of the infused nutrient was determined by scintigraphy. Data are medians (ranges) and were analyzed by using Wilcoxon's signed-rank test. Thirty-two mechanically ventilated patients were studied. Erythromycin increased small intestinal glucose absorption [3-OMG AUC360: 105.2 (28.9-157.0) for erythromycin compared with 91.8 (51.4-147.9) mmol/L · min for placebo P = 0.029] but tended to reduce lipid absorption [cumulative percentage dose (13)CO2 recovered: 10.4 (0-90.6) compared with 22.6 (0-100) % P = 0.06]. A trend to slower transit was observed after erythromycin [300 (39-360) compared with 228 (33-360) min P = 0.07]. Acute administration of erythromycin increases small intestinal glucose absorption in the critically ill, but there was a tendency for the drug to reduce small intestinal lipid absorption and slow transit. These observations have implications for the use of erythromycin as a gastrokinetic drug in the critically ill. This trial was registered in the Australian New Zealand Clinical Trials Registry as ACTRN 12610000615088.
Publisher: American Association for the Advancement of Science (AAAS)
Date: 02-12-2016
Abstract: A pulse of random activity is sufficient for a brain network to retrieve a dormant activity state.
Publisher: Wiley
Date: 06-05-2021
DOI: 10.1002/JPEN.2103
Abstract: Postprandial rise of plasma essential amino acids (EAAs) determines the anabolic effect of dietary protein. Disturbed gastrointestinal function could impair the anabolic response in critically ill patients. Aim was to investigate the postprandial EAA response in critically ill patients and its relation to small‐intestinal function. Twenty‐one mechanically ventilated patients and 9 healthy controls received a bolus containing 100 ml of a formula feed (Ensure) and 2 g of 3‐O‐Methyl‐d‐glucose (3‐OMG) via postpyloric feeding tube. Fasting and postprandial plasma concentrations of EAAs, 3‐OMG, total bile salts, and the gut‐released hormone fibroblast growth factor 19 (FGF19) were measured over a 4‐hour period. Changes over time and between groups were assessed with linear mixed‐effects analysis. Early (0–60 minutes) and total postprandial responses are summarized as the incremental area under the curve (iAUC). At baseline, fasting EAA levels were similar in both groups: 1181 (1055–1276) vs 1150 (1065–1334) μmol·L−1, P = .87. The early postprandial rise in EAA was not apparent in critically ill patients compared with healthy controls (iAUC 60 , −4858 [−6859 to 2886] vs 5406 [3099–16,853] µmol·L −1 ·60 minutes P = .039). Impaired EAA response did not correlate with impaired 3‐OMG response (Spearman ρ 0.32, P = .09). There was a limited increase in total bile salts but no relevant FGF19 response in either group. Postprandial rise of EAA is blunted in critically ill patients and unrelated to glucose absorption measured with 3‐OMG. Future studies should aim to delineate governing mechanisms of macronutrient malabsorption.
Publisher: Elsevier BV
Date: 12-2011
DOI: 10.1016/J.GTC.2011.09.003
Abstract: Gastrointestinal dysmotility is a common feature of critical illness, with a number of significant implications that include malnutrition secondary to reduced feed tolerance and absorption, reflux and aspiration resulting in reduced lung function and ventilator-associated pneumonia, bacterial overgrowth and possible translocation causing nosocomial sepsis. Prokinetic agent administration can improve gastric emptying and caloric delivery, but its effect on nutrient absorption and clinical outcomes is, as yet, unclear. Postpyloric delivery of nutrition has not yet been demonstrated to increase caloric intake or improve clinical outcomes.
Publisher: Wiley
Date: 13-12-2016
DOI: 10.1111/AAS.12844
Abstract: The objectives of this study were to estimate the frequency of occult upper gastrointestinal abnormalities, presence of gastric acid as a contributing factor, and associations with clinical outcomes. Data were extracted for study participants at a single centre who had an endoscopy performed purely for research purposes and in whom treating physicians were not suspecting gastrointestinal bleeding. Endoscopic data were independently adjudicated by two gastroenterologists who rated the likelihood that observed pathological abnormalities were related to gastric acid secretion using a 3-point ordinal scale (unlikely, possible or probable). Endoscopy reports were extracted for 74 patients [age 52 (37, 65) years] undergoing endoscopy on day 5 [3, 9] of ICU admission. Abnormalities were found in 25 (34%) subjects: gastritis/erosions in 10 (14%), nasogastric tube trauma in 8 (11%), oesophagitis in 4 (5%) and non-bleeding duodenal ulceration in 3 (4%). The contribution of acid secretion to observed pathology was rated 'probable' in six subjects (rater #1) and five subjects (rater #2). Prior to endoscopy, 39 (53%) patients were receiving acid-suppressive therapy. The use of acid-suppressive therapy was not associated with the presence of an endoscopic abnormality (present 15/25 (60%) vs. absent 24/49 (49%) P = 0.46). Haemoglobin concentrations, packed red cells transfused and mortality were not associated with mucosal abnormalities (P = 0.83, P > 0.9 and P > 0.9 respectively). Occult mucosal abnormalities were observed in one-third of subjects. The presence of mucosal abnormalities appeared to be independent of prior acid-suppressive therapy and was not associated with reduced haemoglobin concentrations, increased transfusion requirements, or mortality.
Publisher: Springer International Publishing
Date: 2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/CCM.0000000000001715
Abstract: To quantify gallbladder dysfunction during critical illness. Prospective observational comparison study of nutrient-stimulated gallbladder emptying in health and critical illness. Single-centre mixed medical/surgical ICU. Twenty-four mechanically ventilated critically ill patients suitable to receive enteral nutrition were compared with 12 healthy subjects. Participants were studied after an 8-hour fast. Between 0 and 120 minutes, high-fat nutrient (20% intralipid) was infused via a postpyloric catheter into the duodenum at 2 kcal/min. Three-dimensional images of the gallbladder were acquired at 30-minute intervals from –30 to 180 minutes. Ejection fraction (%) was calculated as changes between 0 and 120 minutes. Blood s les were obtained at 30-minute intervals for plasma cholecystokinin. Data are mean ( sd ) or median [interquartile range]. In the critically ill, fasting gallbladder volumes (critically ill, 61 mL [36–100 mL] vs healthy, 22 mL [15–25] mL p 0.001] and wall thickness (0.45 mm [0.15 mm] vs 0.26 mm [0.08 mm] p 0.001] were substantially greater, and sludge was evident in the majority of patients (71% vs 0%). Nutrient-stimulated emptying was incomplete in the critically ill after 120 minutes but was essentially complete in the healthy in iduals (22 mL [9–66 mL] vs 4 mL [3–5 mL] p 0.01]. In five critically ill patients (21%), there was no change in gallbladder volume in response to nutrient, and overall ejection fraction was reduced in the critically ill (50% [8–83%] vs 77 [72–84%] p = 0.01]. There were no differences in fasting or incremental cholecystokinin concentrations. Fasted critically ill patients have larger, thicker-walled gallbladders than healthy subjects and nutrient-stimulated gallbladder emptying is impaired with “gallbladder paresis” occurring in approximately 20%.
Publisher: Elsevier BV
Date: 04-2019
DOI: 10.1016/J.CCC.2018.11.011
Abstract: In health, postprandial glycemic excursions are attenuated via stimulation of insulin secretion, suppression of glucagon secretion, and slowing of gastric emptying. The incretin hormones, glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide, are primary modulators of this response. Drugs have recently been developed that exploit the incretin-axis for the management of type 2 diabetes. There is burgeoning interest in the potential of incretin therapies for the management of acute hyperglycemia in the critically ill. This article outlines basic incretin physiology, highlights relevant pharmacology, and briefly summarizes the literature on incretins for glycemic control in the critically ill.
Publisher: Springer Science and Business Media LLC
Date: 2011
DOI: 10.1186/CC9983
Publisher: Public Library of Science (PLoS)
Date: 27-07-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2019
Publisher: Elsevier BV
Date: 10-2010
DOI: 10.1016/J.CLNU.2010.03.007
Abstract: Isotope breath tests are increasingly used to evaluate the effects of prokinetic drugs on gastric emptying. The aim was to assess intrasubject variability in gastric emptying, when using an isotope breath test in the critically ill. A retrospective analysis of data was undertaken in 12 patients who had gastric emptying measurements on consecutive days using a (13)C-octanoic acid breath test. The gastric emptying coefficient--GEC (a global index for the gastric emptying rate), and the t(50) (calculated time for 50% of meal to empty) were calculated, together with the coefficient of variability for these parameters. Data are mean (SD). Neither GEC (day 1: 3.3 (0.8) vs. day 2: 3.1 (0.6) P = 0.31) nor t(50) (day 1: 127 (43) min vs. day 2: 141 (48) min P = 0.46) were significantly different between the two days. Intrasubject variability was less for GEC (15.6%) than for t(50) (31.8%). There is only modest intrasubject variability in GEC measurements using the (13)C-octanoic acid breath test in critically ill patients. As such, it may be an acceptable measurement tool to assess the effects of prokinetic drugs in this group.
Publisher: Wiley
Date: 09-12-2020
DOI: 10.1002/NCP.10610
Publisher: King Faisal Specialist Hospital and Research Centre
Date: 11-2016
Publisher: Springer Science and Business Media LLC
Date: 24-04-2014
DOI: 10.1007/S00134-014-3287-7
Abstract: Hyperglycaemia is common in the critically ill. The objectives of this study were to determine the prevalence of critical illness-associated hyperglycaemia (CIAH) and recognised and unrecognised diabetes in the critically ill as well as to evaluate the impact of premorbid glycaemia on the association between acute hyperglycaemia and mortality. In 1,000 consecutively admitted patients we prospectively measured glycated haemoglobin (HbA1c) on admission, and blood glucose concentrations during the 48 h after admission, to the intensive care unit. Patients with blood glucose ≥7.0 mmol/l when fasting or ≥11.1 mmol/l during feeding were deemed hyperglycaemic. Patients with acute hyperglycaemia and HbA1c <6.5% (48 mmol/mol) were categorised as 'CIAH', those with known diabetes as 'recognised diabetes', and those with HbA1c ≥6.5% but no previous diagnosis of diabetes as 'unrecognised diabetes'. The remainder were classified as 'normoglycaemic'. Hospital mortality, HbA1c and acute peak glycaemia were assessed using a logistic regression model. Of 1,000 patients, 498 (49.8%) had CIAH, 220 (22%) had recognised diabetes, 55 (5.5%) had unrecognised diabetes and 227 (22.7%) were normoglycaemic. The risk of death increased by approximately 20% for each increase in acute glycaemia of 1 mmol/l in patients with CIAH and those with diabetes and HbA1c levels <7% (53 mmol/mol), but not in patients with diabetes and HbA1c ≥7%. This association was lost when adjusted for severity of illness. Critical illness-associated hyperglycaemia is the most frequent cause of hyperglycaemia in the critically ill. Peak glucose concentrations during critical illness are associated with increased mortality in patients with adequate premorbid glycaemic control, but not in patients with premorbid hyperglycaemia. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia.
Publisher: JMIR Publications Inc.
Date: 09-11-2017
Publisher: SAGE Publications
Date: 07-2017
DOI: 10.1177/0310057X1704500411
Abstract: The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to in idualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid ‘baseline assessment’ was conducted to categorise patients into one of eight specified groups. A subsequent ‘gold standard’ assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in % of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.
Publisher: American Diabetes Association
Date: 16-01-2014
DOI: 10.2337/DB13-0893
Abstract: Acute administration of glucagon-like peptide 1 (GLP-1) and its agonists slows gastric emptying, which represents the major mechanism underlying their attenuation of postprandial glycemic excursions. However, this effect may diminish during prolonged use. We compared the effects of prolonged and intermittent stimulation of the GLP-1 receptor on gastric emptying and glycemia. Ten healthy men received intravenous saline (placebo) or GLP-1 (0.8 pmol/kg ⋅ min), as a continuous 24-h infusion (“prolonged”), two 4.5-h infusions separated by 20 h (“intermittent”), and a 4.5-h infusion (“acute”) in a randomized, double-blind, crossover fashion. Gastric emptying of a radiolabeled mashed potato meal was measured using scintigraphy. Acute GLP-1 markedly slowed gastric emptying. The magnitude of the slowing was attenuated with prolonged but maintained with intermittent infusions. GLP-1 potently diminished postprandial glycemia during acute and intermittent regimens. These observations suggest that short-acting GLP-1 agonists may be superior to long-acting agonists when aiming specifically to reduce postprandial glycemic excursions in the treatment of type 2 diabetes.
Publisher: Springer Science and Business Media LLC
Date: 14-04-2015
Publisher: Society for Neuroscience
Date: 10-04-2018
DOI: 10.1523/JNEUROSCI.2747-17.2018
Abstract: Although the manipulation of load is popular in visual working memory research, many studies confound general attentional demands with context binding by drawing memoranda from the same stimulus category. In this fMRI study of human observers (both sexes), we created high- versus low-binding conditions, while holding load constant, by comparing trials requiring memory for the direction of motion of one random dot kinematogram (RDK 1M trials) versus for three RDKs (3M), or versus one RDK and two color patches (1M2C). Memory precision was highest for 1M trials and comparable for 3M and 1M2C trials. And although delay-period activity in occipital cortex did not differ between the three conditions, returning to baseline for all three, multivariate pattern analysis decoding of a remembered RDK from occipital cortex was also highest for 1M trials and comparable for 3M and 1M2C trials. Delay-period activity in intraparietal sulcus (IPS), although elevated for all three conditions, displayed more sensitivity to demands on context binding than to load per se. The 1M-to-3M increase in IPS signal predicted the 1M-to-3M declines in both behavioral and neural estimates of working memory precision. These effects strengthened along a caudal-to-rostral gradient, from IPS0 to IPS5. Context binding-independent load sensitivity was observed when analyses were lateralized and extended into PFC, with trend-level effects evident in left IPS and strong effects in left lateral PFC. These findings illustrate how visual working memory capacity limitations arise from multiple factors that each recruit dissociable brain systems. SIGNIFICANCE STATEMENT Visual working memory capacity predicts performance on a wide array of cognitive and real-world outcomes. At least two theoretically distinct factors are proposed to influence visual working memory capacity limitations: an amodal attentional resource that must be shared across remembered items and the demands on context binding. We unconfounded these two factors by varying load with items drawn from the same stimulus category (“high demands on context binding”) versus items drawn from different stimulus categories (“low demands on context binding”). The results provide evidence for the dissociability, and the neural bases, of these two theorized factors, and they specify that the functions of intraparietal sulcus may relate more strongly to the control of representations than to the general allocation of attention.
Publisher: Wiley
Date: 02-07-2014
DOI: 10.1002/OBY.20829
Abstract: To determine the effect of Roux-en-Y gastric bypass (RYGB) on the expression of intestinal sweet taste receptors (STRs), glucose transporters (GTs), glucose absorption, and glycemia. Intestinal biopsies were collected for mRNA expression of STR (T1R2) and GTs (SGLT-1 and GLUT2) from 11 non-diabetic RYGB, 13 non-diabetic obese, and 11 healthy subjects, at baseline and following a 30 min small intestinal (SI) glucose infusion (30 g/150 ml water with 3 g 3-O-methyl-d-glucopyranose (3-OMG)). Blood glucose, plasma 3-OMG, and insulin were measured for 270 min. In RYGB patients, expression of both GTs was ∼2-fold higher at baseline and after glucose infusion than those of morbidly obese or healthy subjects (P < 0.001). STR expressions were comparable amongst the groups. Peak plasma 3-OMG in both RYGB (r = 0.69, P = 0.01) and obese (r = 0.72, P = 0.005) correlated with baseline expression of SGLT-1, as was the case with peak blood glucose in RYGB subjects (r = 0.69, P = 0.02). The upregulated intestinal GTs in RYGB patients are associated with increased glucose absorption when glucose is delivered at a physiological rate, suggesting a molecular adaptation to prevent carbohydrate malabsorption from rapid intestinal transit after RYGB.
Publisher: Elsevier BV
Date: 06-2016
Publisher: Wiley
Date: 24-06-2014
Abstract: Adequate nutrition support for critically ill patients optimizes outcome, and enteral feeding is the preferred route of nutrition. Small intestinal glucose absorption is frequently impaired in critical illness. Despite lipid being a major constituent of liquid nutrient administered, there is little information about lipid absorption during critical illness. To determine small intestinal lipid, as well as glucose, absorption in critical illness compared with health. Twenty-nine mechanically ventilated critically ill patients and 16 healthy volunteers were studied. Liquid nutrient (60 mL, 1 kcal/mL), containing 200 µL (13)C-triolein and 3 g 3-O-methyl-glucose (3-OMG), was infused directly into the duodenum at a rate of 2 kcal/min. Exhaled (13)CO2 and serum 3-OMG concentrations were measured at timed intervals over 360 minutes. Lipid absorption was measured as the cumulative percentage dose (cPDR) of (13)CO2 recovered at 360 minutes. Glucose absorption was measured as the area under the 3-OMG concentration curve. Data are median (range) and analyzed using the Mann-Whitney U and Pearson correlation tests. Lipid absorption was markedly less in the critically ill (cPDR(13)CO2: patients, 22.6% [0%-100%] vs healthy participants, 40.7% [5.3%-84.7%] P = .018). While glucose absorption was less at 60 minutes in the critically ill (3-OMG60: 13.2 [3.5-29.5] vs 21.1 [9.3-31.9] mmol/L·min P = .003), this was not apparent at 360 minutes (3-OMG360: 92.7 [54.5-147.9] vs 107.9 [64.0-168.7] mmol/L·min P = .126). There was no relationship between lipid and glucose absorption. Small intestinal absorption of lipid is diminished during critical illness.
Publisher: Wiley
Date: 30-12-2020
DOI: 10.1002/JPEN.2059
Abstract: International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. We conducted a prospective, randomized, blinded, parallel‐group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high‐protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day difference, 0.53 [95% CI, 0.38–0.69] g/kg/d protein), with no difference in energy delivery (difference, −26 [95% CI, −190 to 137] kcal/kg/d). There were no between‐group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90‐day mortality (14/55 [26%] vs 15/56 [27%] risk difference, −1.3% [95% CI, −17.7% to 15.0%]). Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline–recommended levels with doses similar to usual care during critical illness.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2015
Publisher: Elsevier BV
Date: 08-2019
DOI: 10.1016/J.JCRC.2019.01.004
Abstract: Prophylactic laxative bowel regimens may prevent constipation in enterally-fed critically ill patients. However, their use may also increase diarrhea. We performed a systematic review to: 1. Explore the epidemiology of constipation and/or diarrhea in critically ill patients and 2. Appraise trials evaluating prophylactic laxative bowel regimens. We searched MEDLINE, Embase, and CINAHL for publications that reported constipation or diarrhea in critically ill adult patients and/or prophylactic laxative bowel regimens. The proportion of critically ill patients experiencing constipation was reported between 20% and 83% and the proportion experiencing diarrhea was reported between 3.3% and 78%. Six studies of prophylactic laxative bowel regimens were identified but only 3 randomised controlled trials were identified, and these were subjected to meta-analysis. Compared with placebo, a prophylactic laxative bowel regimen increased the risk of diarrhea (RR 1.58, 95% CI 1.22 to 2.04) but did not reduce the risk of constipation (RR 0.39, 95% CI 0.14 to 1.05), and did not affect the duration of mechanical ventilation, duration of ICU admission, or mortality. Constipation and diarrhea occur frequently in the critically ill but data evaluating prophylactic laxative bowel regimens in such patients are sparse and do not support their use.
Publisher: Springer Science and Business Media LLC
Date: 12-2015
DOI: 10.1186/S13054-014-0718-3
Abstract: Insulin is used to treat hyperglycaemia in critically ill patients but can cause hypoglycaemia, which is associated with poorer outcomes. In health glucose-dependent insulinotropic polypeptide (GIP) is a potent glucose-lowering peptide that does not cause hypoglycaemia. The objectives of this study were to determine the effects of exogenous GIP infusion on blood glucose concentrations, glucose absorption, insulinaemia and gastric emptying in critically ill patients without known diabetes. A total of 20 ventilated patients (Median age 61 (range: 22 to 79) years, APACHE II 21.5 (17 to 26), BMI 28 (21 to 40) kg/m 2 ) without known diabetes were studied on two consecutive days in a randomised, double blind, placebo controlled, cross-over fashion. Intravenous GIP (4 pmol/kg/min) or placebo (0.9% saline) was infused between T = −60 to 300 minutes. At T0, 100 ml of liquid nutrient (2 kcal/ml) containing 3-O-Methylglucose (3-OMG), 100 mcg of Octanoic acid and 20 MBq Tc-99 m Calcium Phytate, was administered via a nasogastric tube. Blood glucose and serum 3-OMG (an index of glucose absorption) concentrations were measured. Gastric emptying, insulin and glucagon levels and plasma GIP concentrations were also measured. While administration of GIP increased plasma GIP concentrations three- to four-fold (T = −60 23.9 (16.5 to 36.7) versus T = 0 84.2 (65.3 to 111.1) P .001) and plasma glucagon (iAUC 300 4217 (1891 to 7715) versus 1232 (293 to 4545) pg/ml.300 minutes P = 0.04), there were no effects on postprandial blood glucose (AUC 300 2843 (2568 to 3338) versus 2819 (2550 to 3497) mmol/L.300 minutes P = 0.86), gastric emptying (AUC 300 15611 (10993 to 18062) versus 15660 (9694 to 22618) %.300 minutes P = 0.61), glucose absorption (AUC 300 50.6 (22.3 to 74.2) versus 64.3 (9.9 to 96.3) mmol/L.300 minutes P = 0.62) or plasma insulin (AUC 300 3945 (2280 to 6731) versus 3479 (2316 to 6081) mU/L.300 minutes P = 0.76). In contrast to its profound insulinotropic effect in health, the administration of GIP at pharmacological doses does not appear to affect glycaemia, gastric emptying, glucose absorption or insulinaemia in the critically ill patient. Australian New Zealand Clinical Trials Registry ACTRN12612000488808 . Registered 3 May 2012.
Publisher: Springer Science and Business Media LLC
Date: 08-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2017
DOI: 10.1097/CCM.0000000000002599
Abstract: Surrogate-decision maker and patient self-reported estimates of the distances walked prior to acute illness are subjective and may be imprecise. It may be possible to extract objective data from a patient’s smartphone, specifically, step and global position system data, to quantify physical activity. The objectives were to 1) assess the agreement between surrogate-decision maker and patient self-reported estimates of distance and time walked prior to resting and daily step-count and 2) determine the feasibility of extracting premorbid physical activity (step and global position system) data from critically ill patients. Prospective cohort study. Quaternary ICU. Fifty consecutively admitted adult patients who owned a smartphone, who were ambulatory at baseline, and who remained in ICU for more than 48 hours participated. There was no agreement between patients and surrogates for all premorbid walking metrics (mean bias 108% [99% lower to 8,700% higher], 83% [97% to 2,100%], and 71% [96% to 1,080%], for distance, time, and steps, respectively). Step and/or global position system data were successfully extracted from 24 of 50 phones (48% 95% CI, 35–62%). Surrogate-decision makers, but not patient self-reported, estimates of steps taken per day correlated with smartphone data (surrogates: n = 13, ρ = 0.56, p 0.05 patients: n = 13, ρ = 0.30, p = 0.317). There was a lack of agreement between surrogate-decision maker and patient self-reported subjective estimates of distance walked. Obtaining premorbid physical activity data from the current-generation smartphones was feasible in approximately 50% of patients.
Publisher: Springer Science and Business Media LLC
Date: 19-03-2019
DOI: 10.1007/S00134-019-05594-1
Abstract: The World Health Organization defines overweight and obesity as the condition where excess or abnormal fat accumulation increases risks to health. The prevalence of obesity is increasing worldwide and is around 20% in ICU patients. Adipose tissue is highly metabolically active, and especially visceral adipose tissue has a deleterious adipocyte secretory profile resulting in insulin resistance and a chronic low-grade inflammatory and procoagulant state. Obesity is strongly linked with chronic diseases such as type 2 diabetes, hypertension, cardiovascular diseases, dyslipidemia, non-alcoholic fatty liver disease, chronic kidney disease, obstructive sleep apnea and hypoventilation syndrome, mood disorders and physical disabilities. In hospitalized and ICU patients and in patients with chronic illnesses, a J-shaped relationship between BMI and mortality has been demonstrated, with overweight and moderate obesity being protective compared with a normal BMI or more severe obesity (the still debated and incompletely understood "obesity paradox"). Despite this protective effect regarding mortality, in the setting of critical illness morbidity is adversely affected with increased risk of respiratory and cardiovascular complications, requiring adapted management. Obesity is associated with increased risk of AKI and infection, may require adapted drug dosing and nutrition and is associated with diagnostic and logistic challenges. In addition, negative attitudes toward obese patients (the social stigma of obesity) affect both health care workers and patients.
Publisher: Public Library of Science (PLoS)
Date: 26-10-2022
DOI: 10.1371/JOURNAL.PONE.0276509
Abstract: To use machine learning (ML) to predict short-term requirements for invasive ventilation in patients with COVID-19 admitted to Australian intensive care units (ICUs). A machine learning study within a national ICU COVID-19 registry in Australia. Adult patients who were spontaneously breathing and admitted to participating ICUs with laboratory-confirmed COVID-19 from 20 February 2020 to 7 March 2021. Patients intubated on day one of their ICU admission were excluded. Six machine learning models predicted the requirement for invasive ventilation by day three of ICU admission from variables recorded on the first calendar day of ICU admission (1) random forest classifier (RF), (2) decision tree classifier (DT), (3) logistic regression (LR), (4) K neighbours classifier (KNN), (5) support vector machine (SVM), and (6) gradient boosted machine (GBM). Cross-validation was used to assess the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of machine learning models. 300 ICU admissions collected from 53 ICUs across Australia were included. The median [IQR] age of patients was 59 [50–69] years, 109 (36%) were female and 60 (20%) required invasive ventilation on day two or three. Random forest and Gradient boosted machine were the best performing algorithms, achieving mean (SD) AUCs of 0.69 (0.06) and 0.68 (0.07), and mean sensitivities of 77 (19%) and 81 (17%), respectively. Machine learning can be used to predict subsequent ventilation in patients with COVID-19 who were spontaneously breathing and admitted to Australian ICUs.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2016
DOI: 10.1097/CCM.0000000000001819
Abstract: Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration. Prospective randomized double-blind parallel-group study. University-affiliated mixed medical-surgical ICU. Mechanically ventilated critically ill patients suitable for enteral nutrition. We randomly assigned patients to receive either daily IV placebo or pantoprazole. Major outcomes were clinically significant gastrointestinal bleeding, infective ventilator-associated complication or pneumonia, and Clostridium difficile infection minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3 p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells ( p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97–2.90] p = 0.06). We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation.
Publisher: Elsevier BV
Date: 04-2016
Publisher: Elsevier BV
Date: 05-2019
Publisher: Elsevier BV
Date: 08-2019
DOI: 10.1016/J.JCRC.2019.04.010
Abstract: Prophylactic laxative regimens may prevent constipation but may increase diarrhea and subsequent rectal tube insertion. Our aim was to compare three prophylactic laxative regimens on the rate of rectal tube insertion (primary outcome) and major constipation- or diarrhea-associated complications. We conducted a cluster-crossover trial. Three pods in a single ICU were each randomized to one of three regimens for four months with rolling cross-over. All mechanically-ventilated and enterally-fed adult patients received either regimen: A) one coloxyl with senna BD from day one B) two coloxyl with senna +20 ml lactulose BD commencing on day 3 or C) two coloxyl with senna tablets +20 ml lactulose BD commencing on day 6. We enrolled 570 patients (A = 170, B = 205, C = 195) with similar baseline features. Overall, 53 (9.3%) patients received a rectal tube, and insertion rate was not statistically different between the three regimens (A = 12.9%, B = 7.8%, C = 7.7% p = 0.15). The proportions of patients with other major constipation- or diarrhea-associated complications were similar, as were major patient-centred outcomes. Earlier commencement of a prophylactic coloxyl-based laxative regimen (day 1 or 3) did not affect the rates of complications associated with constipation or diarrhea when compared to delayed introduction (day 6).
Publisher: American Thoracic Society
Date: 10-2020
Publisher: Massachusetts Medical Society
Date: 08-11-2018
Publisher: Wiley
Date: 27-04-2018
DOI: 10.1002/JPEN.1163
Abstract: The Augmented Versus Routine Approach to Giving Energy Trial (TARGET) is the largest blinded enteral nutrition (EN) intervention trial evaluating energy delivery to be conducted in the critically ill. To determine the external validity of TARGET results, nutrition practices in intensive care units (ICUs) in Australia and New Zealand (ANZ) are described and compared with international practices. This was a retrospective analysis of prospectively collected data for the International Nutrition Surveys, 2007-2013. Data are presented as mean (SD). A total of 17,154 patients (ANZ: n = 2776 vs international n = 14,378) from 923 ICUs (146 and 777, respectively) were included. EN was the most common route of feeding (ANZ: 85%, n = 2365 patients vs international: 84%, n = 12,034 P = .258), and EN concentration was also similar (<1.25 kcal/mL ANZ: 70%, n = 12,396 vs international: 65%, n = 56,891 administrations P < .001). Protein delivery was substantially below the estimated prescriptions but similar between the regions (0.6 [0.4] g/kg/day vs 0.6 [0.4] g/kg/day P = .849). Patients in ANZ received slightly more energy (1133 [572] vs 948[536] kcal/day P < .001), possibly because more energy was prescribed (1947 [348] vs 1747 [376] kcal/day P < .001), nutrition protocols were more commonly used (98% vs 75% P < .001) and included recommendations for therapies such as prokinetic agents (87% vs 51%, n = 399 P < .001) and small bowel feeding (62% vs 40% P < .001) when compared with international ICUs. Key elements of nutrition practice are similar in ANZ and international ICUs. These data can be used to determine the external validity and relevance of TARGET results.
Publisher: Wiley
Date: 07-04-2022
DOI: 10.1002/JPEN.2373
Abstract: Induction of ketosis by manipulation of nutrition intake has been proposed as an adjunctive treatment for super‐refractory status epilepticus (SRSE). However, the classical 4:1 ketogenic ratio may not meet the nutrition needs, specifically protein for critically ill adults. The aim of this study was to analyze the outcomes of adults with SRSE who received a lower ketogenic ratio of 2:1 grams of fat to non‐fat grams, including 20%–30% of energy from medium chain triglycerides. We reviewed patients aged ≥18 years with SRSE treated with ketogenic therapy between July 2015 and December 2020 at two quaternary teaching hospitals in Melbourne, Australia. Data collected from medical records included patient demographics, nutrition prescription, clinical outcomes, and ketogenic therapy‐related complications. The primary outcome of the study was to assess tolerability of ketogenic therapy. Twelve patients (female = 7) were treated with ketogenic therapy for SRSE. Patients received between 4 and 8 antiseizure medications and 1–5 anesthetic agents prior to commencement of ketogenic therapy. Blood beta‐hydroxybutyrate concentrations were variable (median = 0.5 mmol/L, range: 0.0–6.1 mmol/L). SRSE resolved in 10 cases (83%) after a median of 9 days (range: 2–21 days) following commencement of ketogenic therapy. Ketogenic therapy–associated complications were reported in five patients, leading to cessation in two patients. Despite the challenge in maintaining ketosis during critical illness, low ratio 2:1 ketogenic therapy incorporating medium chain triglycerides is tolerable for adults with SRSE. Further studies are required to determine the optimal timing, nutrition prescription and duration of ketogenic therapy for SRSE treatment.
Publisher: Springer Science and Business Media LLC
Date: 11-12-2017
Publisher: American Medical Association (AMA)
Date: 04-02-2020
Publisher: Wiley
Date: 28-12-2017
DOI: 10.1002/JPEN.1038
Abstract: Camicinal is a novel, nonmacrolide, motilin receptor agonist that accelerates gastric emptying in critically ill patients with established feed intolerance. The primary question was whether the preemptive administration of camicinal increased the provision of enteral nutrition (EN) to critically ill patients with risk factors that predisposed to feed intolerance. This was an international, multicenter, parallel-group, blinded, randomized controlled trial. Patients at risk for feed intolerance, defined as receiving moderate to high doses of vasopressors or opiates, or admitted because of multiple traumatic injuries or with brain injury, received either enteral camicinal 50 mg or placebo daily for a maximum of 7 days, along with EN administered according to a standardized feeding protocol. The primary outcome was the daily adequacy of enteral feed delivered, as assessed by percentage of goal volume (delivered rescribed × 100) before development of intolerance. Eighty-four patients participated. The administration of camicinal did not result in a statistically significant clinical difference in the daily average percentage goal volume delivered (camicinal vs placebo: 77% [95% confidence interval: 71, 83] vs 68% (58, 78) mean difference 9% [-5, 23] P = 0.21). Similarly, there were no differences in the percentage goal calories (76% [65, 88] vs 68% [60, 77]) and protein (76% [66, 86] vs 70% [61, 80]) administered, or the incidence of feed intolerance (15% vs 14%). The incidence of feed intolerance was low in both groups. In this cohort the preemptive administration of enteral camicinal did not significantly augment the provision of goal EN.
Publisher: The Endocrine Society
Date: 03-2015
DOI: 10.1210/JC.2014-3144
Abstract: Intestinal glucose absorption is mediated by sodium-dependent glucose transporter 1 (SGLT-1) and glucose transporter 2 (GLUT2), which are linked to sweet taste receptor (STR) signaling and incretin responses. This study aimed to examine intestinal glucose absorption in morbidly obese humans and its relationship to the expression of STR and glucose transporters, glycemia, and incretin responses. Seventeen nondiabetic, morbidly obese subjects (body mass index [BMI], 48 ± 4 kg/m(2)) and 11 lean controls (BMI, 25 ± 1 kg/m(2)) underwent endoscopic duodenal biopsies before and after a 30-minute intraduodenal glucose infusion (30 g glucose and 3 g 3-O-methylglucose [3-OMG]). Blood glucose and plasma concentrations of 3-OMG, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1), insulin, and glucagon were measured over 270 minutes. Expression of duodenal SGLT-1, GLUT2, and STR (T1R2) was quantified by PCR. The increase in plasma 3-OMG (P < .001) and blood glucose (P < .0001) were greater in obese than lean subjects. Plasma 3-OMG correlated directly with blood glucose (r = 0.78, P < .01). In response to intraduodenal glucose, plasma GIP (P < .001), glucagon (P < .001), and insulin (P < .001) were higher, but GLP-1 (P < .001) was less in the obese compared with lean. Expression of SGLT-1 (P = .035), but not GLUT2 or T1R2, was higher in the obese, and related to peak plasma 3-OMG (r = 0.60, P = .01), GIP (r = 0.67, P = .003), and insulin (r = 0.58, P = .02). In morbid obesity, proximal intestine glucose absorption is accelerated and related to increased SGLT-1 expression, leading to an incretin-glucagon profile promoting hyperinsulinemia and hyperglycemia. These findings are consistent with the concept that accelerated glucose absorption in the proximal gut underlies the foregut theory of obesity and type 2 diabetes.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.AUCC.2018.04.004
Abstract: Optimising nutrition support in critically ill patients with an open abdomen is challenging. The aims of this study were to (i) quantify the amount and adequacy of nutrition support administered and (ii) determine any relationships that exist between mode of nutrition support delivery and clinical outcomes in critically ill patients with an open abdomen. A retrospective review of critically ill patients mechanically ventilated for at least 48 h with an open abdomen in a mixed quaternary referral intensive care unit. Enteral and parenteral nutrition (ml) administered daily to patients was recorded for up to 21 days. Length of stay in the intensive care unit and hospital and duration of mechanical ventilation (days) were reported. Thirty patients were studied [14 male, 68 y (15-90 y), body mass index 25 kg/m Patients with an open abdomen receive about half of their nutrition requirements when fed exclusively via the enteral route. Providing combination enteral and parenteral nutrition to reach nutritional goals may not result in better clinical outcomes for patients with an open abdomen.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/CCM.0000000000001815
Abstract: The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a “ liberal” approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe. Prospective, open-label, sequential-period exploratory study. Medical-surgical ICU. During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). During the “standard care” period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the “liberal” period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L. Time-weighted mean glucose concentrations and the number and duration of moderate ( 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucose day 0–7 , standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L p 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19–1.13] p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%] p 0.01). Biomarker data and clinical outcomes were similar. In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2017
DOI: 10.1097/CCM.0000000000002461
Abstract: A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients. In 10 ICUs, we randomized adult ICU patients anticipated to be mechanically ventilated for greater than or equal to 48 hours to receive 40 mg of IV pantoprazole daily or placebo. We excluded patients who had acute or recent gastrointestinal bleed, used dual antiplatelet agents, had a medical condition requiring proton pump inhibitor treatment, or had already received more than one dose of acid suppression daily. Patients, families, clinicians, and research staff were blinded. We conducted a systematic review and meta-analysis of similar trials. Ninety-one patients (49 pantoprazole and 42 placebo) from 10 centers in Canada, Saudi Arabia, and Australia were enrolled. All feasibility goals were met: 1) recruitment rate was 2.6 patients per month 2) consent rate was 77.8% and 3) protocol adherence was 97.7%. Upper gastrointestinal bleeding developed in 6.1% of patients in the pantoprazole group and 4.8% in the placebo group ( p = 1.0). Ventilator-associated pneumonia developed in 20.4% of patients in the pantoprazole group and 14.3% in the placebo group ( p = 0.58). C. difficile was identified in 4.1% pantoprazole patients and in 2.4% placebo patients ( p = 1.0). We meta-analyzed five trials (604 patients) of proton pump inhibitors versus placebo there was no statistically significant difference in the risk of upper gastrointestinal bleeding, infections, or mortality. Our results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis. Although the results are imprecise, there was no alarming increase in the risk of upper gastrointestinal bleeding the effect of proton pump inhibitors on ventilator-associated pneumonia and C. difficile remain unclear.
Publisher: Wiley
Date: 25-06-2023
DOI: 10.1002/JPEN.2527
Abstract: Beta‐hydroxy‐beta‐methylbutyrate (HMB) is a nutrition supplement that may attenuate muscle wasting from critical illness. This trial aimed to determine feasibility of administering a blinded nutrition supplement in the intensive care unit (ICU) and continuing it after ICU discharge. Single‐center, parallel‐group, blinded, placebo‐controlled, randomized feasibility trial. After traumatic injury necessitating admission to ICU, participants were randomized to receive an enteral study supplement of 3 g of HMB (intervention) or placebo daily for 28 days or until hospital discharge. Primary outcome was feasibility of administering the study supplement, quantified as protocol adherence. Secondary outcomes included change in quadriceps muscle thickness, measured weekly until day 28 or hospital discharge by using ultrasound and analyzed by using a linear mixed model. Fifty randomized participants (intervention, n = 26 placebo, n = 24) showed comparable baseline characteristics. Participants received 862 (84.3%) of the 1022 prescribed supplements during hospitalization with 543 (62.8%) delivered via an enteral feeding tube. The median (IQR) number of study supplements successfully administered per participant was 19.5 (13.0–24.0) in the intervention group and 16.5 (8.5–23.5) in the placebo group. Marked loss of quadriceps muscle thickness occurred in both groups, with the point estimate favoring attenuated muscle loss with the intervention, albeit with wide CIs (mean intervention difference after 28 days, 0.26 cm [95% CI, −0.13 to 0.64]). A blinded, placebo‐controlled, randomized clinical trial of daily enteral HMB supplementation for up to 28 days in hospital is feasible. Any effect of HMB supplementation to attenuate muscle wasting after traumatic injury remains uncertain.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1097/CCM.0000000000001656
Abstract: Glycated hemoglobin A1c is used to estimate glycemic control. However, its value upon ICU admission may be altered by critical illness and not reflect true glycemic status. We assessed the relationship between ICU admission glycated hemoglobin A1c and premorbid glycated hemoglobin A1c levels. Retrospective observational cohort study. Two tertiary ICUs in Australia. Cohort of 69 critically ill patients with diabetes and glycated hemoglobin A1c levels measured upon ICU admission and during the month prior to admission. Measurement of glycated hemoglobin A1c. Mean ( sd ) glycated hemoglobin A1c level was 7.5% (1.8%) upon ICU admission and 7.8% (2.0%) in previous measurements from the preceding 30 days. The change in glycated hemoglobin A1c did not correlate with time elapsed between the two measurements ( r 2 = 0.00005 p = 0.95), but there was a strong correlation between admission glycated hemoglobin A1c levels and premorbid glycated hemoglobin A1c levels ( r 2 = 0.89 p 0.001). Glycated hemoglobin A1c levels are not altered by the onset of critical illness. Glycated hemoglobin A1c quantified at ICU admission can, therefore, be used to reliably estimate chronic glycemic control and guide acute glycemic therapy.
Publisher: American Thoracic Society
Date: 10-2022
Publisher: Elsevier BV
Date: 11-2019
DOI: 10.1053/J.JVCA.2019.03.049
Abstract: To compare the effects of fluid bolus therapy using 20% albumin versus crystalloid on fluid balance, hemodynamic parameters, and intensive care unit (ICU) treatment effects in post-cardiac surgery patients. Sequential period open-label pilot study. University teaching hospital. One hundred adult cardiac surgery patients who were prescribed fluid bolus therapy to correct hypotension or perceived hypovolemia or to optimize cardiac index during the first 24 hours in the ICU. The first 50 patients were treated with crystalloid fluid bolus therapy in the first period (control), and 50 patients with up to 2 treatments of 100 mL of 20% albumin fluid bolus therapy in the second period (intervention), followed by crystalloid therapy if needed. Demographic characteristics were similar at baseline. The intervention was associated with a less positive median fluid balance in the first 24 hours (albumin: 1,100 [650-1,960] v crystalloid: 1,970 [1,430-2,550] p = 0.001), fewer episodes of fluid bolus therapy (3 [2-5] v 5 [4-7] p < 0.0001) and a lesser volume of fluid bolus therapy (700 [200-1,450] v 1,500 mL/24 h [1,100-2,250] p < 0.0001). The intervention also was associated with a decreased median overall dose of norepinephrine in the first 24 hours of ICU stay (19 [0-52] v 47 µg/kg/24 hours [0-134] p = 0.025) and shorter median time to cessation of norepinephrine (17 [5-28] v 28 hours [20-48] p = 0.002). Post-cardiac surgery fluid bolus therapy with 20% albumin when compared with crystalloid fluid resulted in less positive fluid balance as well as several hemodynamic and potential ICU treatment advantages.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.DIABRES.2017.10.029
Abstract: It remains uncertain if stress hyperglycaemia (SH) indicates a long-term predisposition to the development of type 2 diabetes. We conducted a retrospective observational study in critically ill patients and found SH to be associated with an increased HbA1c, which may indicate an increased risk of type 2 diabetes.
Publisher: Elsevier BV
Date: 03-2021
DOI: 10.51893/2021.1.OA9
Abstract: Objectives: Overweight patients are at greater risk of venous thromboembolism. We aimed to describe prescribing patterns of thrombosis chemoprophylaxis in critically ill patients weighing ≥ 100 kg and quantify the effectiveness of these regimens using the surrogate biomarker of plasma anti-Xa level. Design, setting and patients: A prospective single-centre cohort study was conducted over a 6-month period. Patients weighing ≥ 100 kg who were prescribed enoxaparin for chemoprophylaxis and expected to remain in the intensive care unit for 48 hours were eligible. Anti-Xa levels were measured once a patient had received at least three consecutive doses of enoxaparin. Peak levels were measured 4–6 hours after the third dose and trough levels were measured before the fourth dose. Anti-Xa levels were compared with established target ranges for peak and trough anti-Xa levels (0.2–0.5 IU/mL and 0.1 IU/mL, respectively). Results: Eighty-eight patients met the eligibility criteria, and anti-Xa levels for 42 patients were obtained. Fixed dose chemoprophylaxis approaches varied considerably, with 40 mg once daily (54/88 [61%]) and 40 mg twice daily (20/88 [23%]) being the most frequently prescribed regimens. No patient had a peak anti-Xa level 0.5 IU/mL. When comparing 40 mg once daily versus twice daily, the once daily regimen had lower median trough levels (0.01 IU/mL [interquartile range (IQR), 0.00–0.04] v 0.09 IU/mL [IQR, 0.05–0.13] P 0.001) and greater proportions of patients with levels below the established range ( 0.1 IU/mL) (15/16 [95%] v 7/14 [50%] P = 0.002) and levels that were undetectable (0.00 IU/mL) (8/16 [50%] v 1/14 [7%] P = 0.01). Conclusions: At a single centre, thrombosis chemoprophylaxis prescribing patterns for heavier critically ill patients varied considerably. Current fixed dose approaches may be inadequate in this cohort
Publisher: Springer Science and Business Media LLC
Date: 08-03-2013
DOI: 10.1007/S00134-013-2881-4
Abstract: Scintigraphy is considered the most accurate technique for the measurement of gastric emptying (GE) but, for patients in the intensive care unit, it is technically demanding, involves radiation and can interfere with care. The (13)C-octanoate breath test ((13)C-OBT) is a simple, non-invasive technique that does not involve radiation exposure. To evaluate the performance of the (13)C-OBT in the assessment of GE in critically ill patients. The GE was assessed in 33 mechanically ventilated patients (23 M 54.3 ± 3.0 yrs APACHE II: 22.0 ± 1.1). Following test meal administration (100 ml Ensure(®)), concurrent scintigraphic measurement and breath s les ((13)C-OBT) were collected over 4 h. Scintigraphic meal retention was determined and the gastric emptying coefficient (GEC) and half emptying time [t50(BT)] were calculated for the (13)C-OBT. Delayed GE was defined as meal retention >13 % at 180 min. Delayed GE was identified in 27/33 patients. Meal retention correlated modestly with t50(BT) (r = 0.55-0.66 P < 0.001) and well with GEC (r = -0.63 to -0.74 P 250 ml) on scintigraphy and 91 % (21/23) patients on (13)C-OBT. In critical illness, there was a correlation between (13)C-OBT and gastric scintigraphy, with GEC performing as a better and more sensitive marker of detecting delayed GE than t50. However the relatively wide 95 % confidence intervals suggest that (13)C-OBT is more suitable as a technique to assess GE in a group setting for research studies rather than for in idual patients in clinical practice.
Publisher: Wiley
Date: 02-06-2015
Abstract: Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. "Energy-dense formulae" (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy-dense formulae in critically ill patients. In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100-mL "meal" containing either standard calories (1 kcal/mL) or concentrated calories (energy-dense formulae 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. Forty patients were studied (n = 18, energy-dense formulae n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy-dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy-dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2010
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.CLNU.2014.11.003
Abstract: Enteral nutrition is important in critically ill patients and is usually administered via a nasogastric tube. As gastric emptying is frequently delayed, and this compromises the delivery of nutrient, it is important that the emptying rate can be quantified. A comprehensive search of MEDLINE/PubMed, of English articles, from inception to 1 July 2014. References of included manuscripts were also examined for additional studies. A number of methods are available to measure gastric emptying and these broadly can be categorised as direct- or indirect-test and surrogate assessments. Direct tests necessitate visualisation of the stomach contents during emptying and are unaffected by liver or kidney metabolism. The most frequently used direct modality is scintigraphy, which remains the 'gold standard'. Indirect tests use a marker that is absorbed in the proximal small intestine, so that measurements of the marker, or its metabolite measured in plasma or breath, correlates with gastric emptying. These tests include drug and carbohydrate absorption and isotope breath tests. Gastric residual volumes (GRVs) are used frequently to quantify gastric emptying during nasogastric feeding, but these measurements may be inaccurate and should be regarded as a surrogate measurement. While the inherent limitations of GRVs make them less suitable for research purposes they are often the only technique that is available for clinicians at the bedside. Each of the available techniques has its strength and limitations. Accordingly, the choice of gastric emptying test is dictated by the particular requirement(s) and expertise of the investigator or clinician.
Publisher: Springer Science and Business Media LLC
Date: 12-2015
Publisher: Springer International Publishing
Date: 2016
Publisher: Wiley
Date: 12-2015
DOI: 10.1111/ANAE.13310
Abstract: Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting the role of nutritional supplementation the optimal route and timing of nutrient delivery and the nutritional management of specific groups including critically ill, obese and elderly patients.
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.CLNU.2018.05.002
Abstract: Oral intake is diminished immediately after ICU discharge, yet factors affecting nutritional intake after hospital discharge have not been evaluated. The aim of this study was to evaluate dietary intake and factors which may influence intake - appetite and gastric emptying - 3-months after ICU discharge. Inception cohort study with ICU survivors compared to healthy subjects. Following an overnight fast, all participants consumed a standardized carbohydrate drink, containing Fifty-one ICU survivors (82% male 70 ± 9 y BMI 28 ± 6 kg/m ICU survivors reported less preference for fat and less calorie consumption than healthy subjects. However, intake of calories and macronutrients at a weighed meal was similar in the two groups, as was the rate of gastric emptying. ICU survivors reported being less full after the test meal, suggesting factors other than appetite may influence intake.
Publisher: American Diabetes Association
Date: 17-03-2015
DOI: 10.2337/DC14-3091
Abstract: Acute hyperglycemia markedly slows gastric emptying. Exogenous GLP-1 also slows gastric emptying, leading to diminished glycemic excursions. The primary objective was to determine whether hyperglycemia potentiates the slowing of gastric emptying induced by GLP-1 administration. Ten healthy participants were studied on 4 separate days. Blood glucose was cl ed at hyperglycemia using an intravenous infusion of 25% dextrose (∼12 mmol/L hyper) on 2 days, or maintained at euglycemia (∼6 mmol/L eu) on 2 days, between t = −15 and 240 min. During hyperglycemic and euglycemic days, participants received intravenous GLP-1 (1.2 pmol/kg/min) and placebo in a randomized double-blind fashion. At t = 0 min, subjects ingested 100 g beef mince labeled with 20 MBq technetium-99m–sulfur colloid and 3 g 3-O-methyl-glucose (3-OMG), a marker of glucose absorption. Gastric emptying was measured scintigraphically from t = 0 to 240 min and serum 3-OMG taken at regular intervals from t = 15 to 240 min. The areas under the curve for gastric emptying and 3-OMG were analyzed using one-way repeated-measures ANOVA with Bonferroni-Holm adjusted post hoc tests. Hyperglycemia slowed gastric emptying (eu lacebo vs. hyper lacebo P & 0.001) as did GLP-1 (eu lacebo vs. eu/GLP-1 P & 0.001). There was an additive effect of GLP-1 and hyperglycemia, such that gastric emptying was markedly slower compared with GLP-1 administration during euglycemia (eu/GLP-1 vs. hyper/GLP-1 P & 0.01). Acute administration of exogenous GLP-1 profoundly slows gastric emptying during hyperglycemia in excess of the slowing induced by GLP-1 during euglycemia. Studies are required to determine the effects of hyperglycemia on gastric emptying with the subcutaneously administered commercially available GLP-1 agonists in patients with type 2 diabetes.
Publisher: Mary Ann Liebert Inc
Date: 02-2012
Abstract: The last 10 years witnessed a considerable increase in our knowledge of brain function in survivors to severe brain injuries with disorders of consciousness (DOC). At the same time, a growing interest developed for the use of functional neuroimaging as a new diagnostic tool in these patients. In this context, particular attention has been devoted to connectivity studies-as these, more than measures of brain metabolism, may be more appropriate to capture the dynamics of large populations of neurons. Here, we will review the pros and cons of various connectivity methods as potential diagnostic tools in brain-damaged patients with DOC. We will also discuss the relevance of the study of the level versus the contents of consciousness in this context.
Publisher: Springer Science and Business Media LLC
Date: 20-08-2014
Publisher: Elsevier BV
Date: 08-2014
Abstract: Critically ill patients typically receive ∼60% of estimated calorie requirements. We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes. A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for ≥2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent. The 2 groups had similar baseline characteristics (1.5 compared with 1.0 kcal/mL). The mean (±SD) age was 56.4 ± 16.8 compared with 56.5 ± 16.1 y, 74% compared with 75% were men, and the Acute Physiology and Chronic Health Evaluation II score was 23 ± 9.1 compared with 22 ± 8.9. The groups received similar volumes of enteral nutrition solution [1221 mL/d (95% CI: 1120, 1322 mL/d) compared with 1259 mL/d (95% CI: 1143, 1374 mL/d) P = 0.628], which led to a 46% increase in daily calories in the group given the 1.5-kcal/mL solution [1832 kcal/d (95% CI: 1681, 1984 kcal/d) compared with 1259 kcal/d (95% CI: 1143, 1374 kcal/d) P < 0.001]. The 1.5-kcal/mL solution was not associated with larger gastric residual volumes or diarrhea. In this feasibility study, there was a trend to a reduced 90-d mortality in patients given 1.5 kcal/mL [11 patients (20%) compared with 20 patients (37%) P = 0.057]. The substitution of a 1.0- with a 1.5-kcal/mL enteral nutrition solution administered at the same rate resulted in a 46% greater calorie delivery without adverse effects. The results support the conduct of a large-scale trial to evaluate the effect of increased calorie delivery on clinically important outcomes in the critically ill.
Publisher: Wiley
Date: 20-07-2020
DOI: 10.1002/JPEN.1949
Publisher: Elsevier BV
Date: 03-2019
DOI: 10.1016/J.AUCC.2019.01.009
Abstract: Physical activity after intensive care unit (ICU) discharge is challenging to measure but could inform research and practice. A patient's smartphone may provide a novel method to quantify physical activity. We aimed to evaluate the feasibility and accuracy of using smartphone step counts among survivors of critical illness. We performed a prospective observational cohort study in 50 patients who had an ICU length of stay>48 h, owned a smartphone, were ambulatory before admission, and were likely to attend follow-up at 3 and 6 months after discharge. At follow-up, daily step counts were extracted from participants' smartphones and two FitBit pedometers, and exercise capacity (6-min walk test) and quality of life (European Quality of Life-5 Dimensions) were measured. Thirty-nine (78%) patients returned at 3 months and 33 (66%) at 6 months, the median [interquartile range] smartphone step counts being 3372 [1688-5899] and 2716 [1717-5994], respectively. There was a strong linear relationship, with smartphone approximating 0.71 (0.58, 0.84) of FitBit step counts, P < 0.0001, R-squared = 0.87. There were weak relationships between step counts and the 6-min walk test distance. Although smartphone ownership and data acquisition limit the viability of using extracted smartphone steps at this time, mean daily step counts recorded using a smartphone may act as a surrogate for a dedicated pedometer however, the relationship between step counts and other measures of physical recovery remains unclear.
No related grants have been discovered for Adam Deane.