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Hsieh PH, Yang TC, Kang EYN, Lee PC, Luo JC, Huang YH, Hou MC, Huang SP. Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials. J Intern Med 2024; 295:759-773. [PMID: 38561603 DOI: 10.1111/joim.13782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model. METHODS This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation. RESULTS A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases. CONCLUSION For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.
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Affiliation(s)
- Ping-Han Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Enoch Yi-No Kang
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Abstract
OBJECTIVE The first 70 years of critical care can be considered a period of "industrial revolution-like" advancement in terms of progressing the understanding and care of critical illness. Unfortunately, like the industrial revolution's impact on the environment, advancing ICU care of increasingly elderly, immunosuppressed, and debilitated individuals has resulted in a greater overall burden and complexity of nosocomial infections within modern ICUs. Given the rapid evolution of nosocomial infections, the authors provide an updated review. DATA SOURCES AND STUDY SELECTION We searched PubMed and OVID for peer-reviewed literature dealing with nosocomial infections in the critically ill, as well as the websites of government agencies involved with the reporting and prevention of nosocomial infections. Search terms included nosocomial infection, antibiotic resistance, microbiome, antibiotics, and intensive care. DATA EXTRACTION AND DATA SYNTHESIS Nosocomial infections in the ICU setting are evolving in multiple domains including etiologic pathogens plus novel or emerging pathogens, prevalence, host risk factors, antimicrobial resistance, interactions of the host microbiome with nosocomial infection occurrence, and understanding of pathogenesis and prevention strategies. Increasing virulence and antimicrobial resistance of nosocomial infections mandate increasing efforts toward their prevention. CONCLUSIONS Nosocomial infections are an important determinant of outcome for patients in the ICU setting. Systematic research aimed at improving the prevention and treatment of nosocomial infections is still needed.
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Jung CY, Bae JM. Pathophysiology and protective approaches of gut injury in critical illness. Yeungnam Univ J Med 2020; 38:27-33. [PMID: 33022904 PMCID: PMC7787898 DOI: 10.12701/yujm.2020.00703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/31/2020] [Indexed: 12/14/2022] Open
Abstract
The gut is a complex organ that has played an important role in digestion, absorption, endocrine functions, and immunity. The gut mucosal barriers consist of the immunologic barrier and nonimmunologic barrier. During critical illnesses, the gut is susceptible to injury due to the induction of intestinal hyperpermeability. Gut hyperpermeability and barrier dysfunction may lead to systemic inflammatory response syndrome. Additionally, gut microbiota are altered during critical illnesses. The etiology of such microbiome alterations in critical illnesses is multifactorial. The interaction or systemic host defense modulation between distant organs and the gut microbiome is increasingly studied in disease research. No treatment modality exists to significantly enhance the gut epithelial integrity, permeability, or mucus layer in critically ill patients. However, multiple helpful approaches including clinical and preclinical strategies exist. Enteral nutrition is associated with an increased mucosal barrier in animal and human studies. The trophic effects of enteral nutrition might help to maintain the intestinal physiology, prevent atrophy of gut villi, reduce intestinal permeability, and protect against ischemia-reperfusion injury. The microbiome approach such as the use of probiotics, fecal microbial transplantation, and selective decontamination of the digestive tract has been suggested. However, its evidence does not have a high quality. To promote rapid hypertrophy of the small bowel, various factors have been reported, including the epidermal growth factor, membrane permeant inhibitor of myosin light chain kinase, mucus surrogate, pharmacologic vagus nerve agonist, immune-enhancing diet, and glucagon-like peptide-2 as preclinical strategies. However, the evidence remains unclear.
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Affiliation(s)
- Chang Yeon Jung
- Department of Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Jung Min Bae
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Chen TH, Su CH, Hsiao CY, Kao SY, Tsai PJ. Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy. J Chin Med Assoc 2020; 83:661-668. [PMID: 32628429 DOI: 10.1097/jcma.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD. METHODS Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line. RESULTS After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation. CONCLUSION Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.
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Affiliation(s)
- Tien-Hua Chen
- Institute of Anatomy and Cell Biology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Trauma Center, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chen-Yuan Hsiao
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Landseed International Hospital, Taoyuan, Taiwan, ROC
| | - Shih-Yi Kao
- Ten-Chan General Hospital Zhongli, Taoyuan, Taiwan, ROC
| | - Pei-Jiun Tsai
- Institute of Anatomy and Cell Biology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Trauma Center, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taiwan, ROC
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Chen W, Wang H, Chen Y, Yuan D, Chen R. The independent risk factors of early diarrhoea in enteral nutrition for ICU patients. J Int Med Res 2019; 47:4929-4939. [PMID: 31507229 PMCID: PMC6833384 DOI: 10.1177/0300060519868340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To investigate the prevalence of and factors associated with diarrhoea in the early stage of enteral nutrition in critically ill patients in intensive care units (ICUs). Methods This prospective, multicentre, observational study enrolled consecutive patients who were newly admitted to ICUs and received enteral nutrition treatment. Events were observed continuously for 7 days or until patients were transferred out of the ICU after enteral nutrition. Demographic and clinical data, enteral nutrition data, diarrhoea-related data and outcomes were recorded. A multivariate logistic regression analysis was used to analyse the risk factors for diarrhoea. Results The study included 533 patients, of whom 164 (30.8%) developed diarrhoea. Diarrhoea was most commonly observed on the first to third days after starting enteral nutrition treatment. The median (interquartile range) duration of diarrhoea was 2 (1–3) days. The administration of gastrointestinal prokinetic agents, the increase in acute physiological and chronic health scores and the pyloric posterior feeding method were independent risk factors for diarrhoea. Conclusion The increased severity of illness, the administration of gastrointestinal prokinetic agents and the pyloric posterior feeding method were independent risk factors for diarrhoea in critically ill ICU patients undergoing enteral nutrition treatment.
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Affiliation(s)
- Weiting Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Hehao Wang
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Yingzi Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Danqin Yuan
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
| | - Renhui Chen
- Department of Critical Care Medicine, Taizhou Hospital of Integrated Traditional Chinese and Western Medicine in Zhejiang, Wenlin, Zhejiang Province, China
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Gut rest strategy and trophic feeding in the acute phase of critical illness with acute gastrointestinal injury. Nutr Res Rev 2019; 32:176-182. [PMID: 30919797 DOI: 10.1017/s0954422419000027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Critically ill patients frequently suffer from gastrointestinal dysfunction as the intestine is a vulnerable organ. In critically ill patients who require nutritional support, the current guidelines recommend the use of enteral nutrition within 24-48 h and advancing towards optimal nutritional goals over the next 48-72 h; however, this may be contraindicated in patients with acute gastrointestinal injury because overuse of the gut in the acute phase of critical illness may have an adverse effect on the prognosis. We propose that trophic feeding after 72 h, as a partial gut rest strategy, should be provided to critically ill patients during the acute phase of illness as an organ-protective strategy, especially for those with acute gastrointestinal injury.
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Ziesmann MT, Marshall JC. Multiple Organ Dysfunction: The Defining Syndrome of Sepsis. Surg Infect (Larchmt) 2018; 19:184-190. [PMID: 29360419 DOI: 10.1089/sur.2017.298] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sepsis as a process has been recognized since the time of the Ancient Greeks. The concept has evolved recently to reflect a disease process of a severe, systemic response to infection. Acute, life-threatening but potentially reversible organ dysfunction is its hallmark, and unresolving organ dysfunction is the dominant cause of death in critical illness. Its evolution, persistence, and resolution reflect a complex interplay of factors originating in the initial inciting insult, the innate immune and metabolic response of the host, and the beneficial and harmful consequences of intensive care unit (ICU) supportive care. DISCUSSION We describe the common clinical manifestations of the six prototypic organ system dysfunction syndromes of severe sepsis and review the associated epidemiology and suspected pathophysiology.
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Affiliation(s)
- Markus T Ziesmann
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario, Canada
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario, Canada
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Kadamani I, Itani M, Zahran E, Taha N. Incidence of aspiration and gastrointestinal complications in critically ill patients using continuous versus bolus infusion of enteral nutrition: A pseudo-randomised controlled trial. Aust Crit Care 2014; 27:188-93. [DOI: 10.1016/j.aucc.2013.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Revised: 11/29/2013] [Accepted: 12/24/2013] [Indexed: 01/15/2023] Open
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Lehmann C, Pavlovic D, Zhou J, Wuttke U, Saeger D, Spassov A, Hung O, Cerny V, Witter T, Whynot S, Suchner U, Alteheld B, Stehle P, Gründling M. Intravenous free and dipeptide-bound glutamine maintains intestinal microcirculation in experimental endotoxemia. Nutrition 2012; 28:588-93. [PMID: 22222295 DOI: 10.1016/j.nut.2011.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 09/28/2011] [Accepted: 09/29/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The administration of glutamine (Gln), which is depleted in critical illness, is associated with an improvement of gut metabolism, structure, and function. The aim of the present study was to evaluate the effects of intravenous Gln and its galenic formulation, l-alanyl-l-glutamine dipeptide (AlaGln), on the intestinal microcirculation during experimental endotoxemia using intravital fluorescence microscopy. Gln or AlaGln administration was performed as pretreatment or post-treatment, respectively. To identify further the underlying mechanisms, amino acid levels were studied. METHODS Sixty male Lewis rats were randomly divided into six groups (n = 10/group): control, LPS (lipopolysaccharide 5 mg/kg intravenously), Gln/LPS (LPS animals pretreated with Gln 0.75 g/kg Gln intravenously), AlaGln/LPS (LPS animals pretreated with AlaGln intravenously, 0.75 g/kg Gln content), LPS/Gln (LPS animals post-treated with Gln 0.75 g/kg intravenously), and LPS/AlaGln (LPS animals post-treated with AlaGln intravenously, 0.75 g/kg Gln content). Two hours after the endotoxin challenge, the microcirculation of the terminal ileum was studied using intravital fluorescence microscopy. Blood samples were drawn at the beginning, during, and the end of the experiment to determine the amino acid levels. RESULTS The Gln and AlaGln pre- and post-treatment, respectively, prevented the LPS-induced decrease in the functional capillary density of the intestinal muscular and mucosal layers (P < 0.05). The number of adherent leukocytes in the submucosal venules was significantly attenuated after the Gln and AlaGln pre- and post-treatment (P < 0.05). CONCLUSION The Gln and AlaGln administrations improved the intestinal microcirculation by increasing the functional capillary density of the intestinal wall and decreasing the submucosal leukocyte activation.
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Affiliation(s)
- Christian Lehmann
- Department of Anesthesia, Ernst-Moritz-Arndt-Universität, Greifswald, Germany.
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Btaiche IF, Chan LN, Pleva M, Kraft MD. Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract 2010; 25:32-49. [PMID: 20130156 DOI: 10.1177/0884533609357565] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.
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Affiliation(s)
- Imad F Btaiche
- University of Michigan Hospitals and Health Centers, Pharmacy Services, UHB2D301, 1500 E. Med. Center Drive, Ann Arbor, MI 48109-0008, USA.
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Zhuang Y, Zhang YP, Ma SY. Protective effect of Fab' in immunoglobulin Y against lipopolysaccharide on intestinal mucosa during the early stage in severely burned gut-derived endotoxemia mice. Shijie Huaren Xiaohua Zazhi 2008; 16:1402-1406. [DOI: 10.11569/wcjd.v16.i13.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the protective effect of Fab' against endotoxin on intestinal mucosa during the early stage in severely burned gut-derived endotoxemia mice, and to explore a new method for preventing and curing burn sepsis.
METHODS: The severely burned gut-derived endotoxemia mice model was used, and the mice were divided into 3 groups: control group (group A), burn group (group B) and Fab' treatment group (group C). At the 6th, 12th, 24th and 48th h after burn injury, the levels of serum tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and interleukin-10 (IL-10) were determined by enzyme-linked immunosorbent assay. Intestinal tissues were collected for pathological examination.
RESULTS: In comparison with those in group A, the levels of serum TNF-α, IL-1β and IL-10 in group B increased significantly and reached the peak 24 h after burn injury (TNF-α: 242.06 ± 3.93 ng/L vs 14.98 ± 1.13 ng/L; IL-1β: 37.86 ± 5.88 ng/L vs 14.39 ± 2.43 ng/L; IL-10: 324.78 ± 65.82 ng/L vs 97.63 ± 20.48 ng/L; all P < 0.01). The levels of TNF-α, IL-1β and IL-10 at 6, 12, 24 and 48 h in group C (6 h: 99.69 ± 10.67, 19.19 ± 1.17, 160.44 ± 24.99 ng/L; 12 h: 172.07 ± 22.47, 22.29 ± 3.32, 185.44 ± 22.30 ng/L; 24 h: 125.98 ± 6.93, 28.39 ± 2.59, 237.11 ± 30.28 ng/L; 48 h: 107.88 ± 5.24, 26.23 ± 2.51, 207.86 ± 20.35 ng/L) were significantly different from those in group B (all P < 0.05). Pathological examination showed a lower degree of intestinal mucosal injury in group C than in compared with group B.
CONCLUSION: The Fab' against endotoxin can significantly decrease the level of serum TNF-α, IL-1β and IL-10 during the early stage in severely burned gut-derived endotoxemia mice, and consequently alleviate the endotoxin-induced injury.
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Devlin JW, Barletta JF. Principles of Drug Dosing in Critically Ill Patients. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tamion F, Richard V, Renet S, Thuillez C. Intestinal preconditioning prevents inflammatory response by modulating heme oxygenase-1 expression in endotoxic shock model. Am J Physiol Gastrointest Liver Physiol 2007; 293:G1308-14. [PMID: 17823216 DOI: 10.1152/ajpgi.00154.2007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Gut mucosal injury observed during ischemia-reperfusion is believed to trigger a systemic inflammatory response leading to multiple organ failure. It should be interesting to demonstrate this relationship between gut and multiple organ failure in a sepsis model. Intestinal preconditioning (PC) can be used as a tool to assess the effect of intestinal ischemia in inflammatory response after LPS challenge. The aim of this study was to investigate the protective effect of PC against LPS-induced systemic inflammatory and intestinal heme oxygenase-1 (HO-1) expression. ES was performed with LPS (10 mg/kg iv) with or without PC, which was done before LPS. Rats were first subjected to sham surgery or PC with four cycles of 1 min ischemia and 4 min of reperfusion 24 h before LPS challenge or saline administration. PC significantly reduced fluid requirements, lung edema, intestinal lactate production, and intestinal injury. Inflammatory mRNA expressions for intestine and lung ICAM and TNF were significantly reduced after PC, and these effects were significantly abolished by zinc-protoporphyrin (a specific HO-1 activity inhibitor) and mimicked by bilirubin administration. Intestinal PC selectively increased HO-1 mRNA expression in intestine, but we have observed no expression in lungs. These findings demonstrate that intestinal injury is a important event for inflammatory response and multiple organ injury after LPS challenge. Intestinal HO-1 expression attenuates LPS-induced multiple organ failure by modulating intestine injury and its consequences on inflammatory response. Identification of the exact mechanisms responsible for intestine HO-1 induction may lead to the development of new pharmacological interventions.
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Affiliation(s)
- Fabienne Tamion
- Institut National de la Santé et de la Recherche Médicale U644, Rouen University Medical School, Rouen, France.
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Zaborina O, Lepine F, Xiao G, Valuckaite V, Chen Y, Li T, Ciancio M, Zaborin A, Petroff E, Turner JR, Rahme LG, Chang E, Alverdy JC. Dynorphin activates quorum sensing quinolone signaling in Pseudomonas aeruginosa. PLoS Pathog 2007; 3:e35. [PMID: 17367209 PMCID: PMC1828698 DOI: 10.1371/journal.ppat.0030035] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Accepted: 01/24/2007] [Indexed: 01/17/2023] Open
Abstract
There is now substantial evidence that compounds released during host stress directly activate the virulence of certain opportunistic pathogens. Here, we considered that endogenous opioids might function as such compounds, given that they are among the first signals to be released at multiple tissue sites during host stress. We tested the ability of various opioid compounds to enhance the virulence of Pseudomonas aeruginosa using pyocyanin production as a biological readout, and demonstrated enhanced virulence when P. aeruginosa was exposed to synthetic (U-50,488) and endogenous (dynorphin) κ-agonists. Using various mutants and reporter strains of P. aeruginosa, we identified involvement of key elements of the quorum sensing circuitry such as the global transcriptional regulator MvfR and the quorum sensing-related quinolone signaling molecules PQS, HHQ, and HQNO that respond to κ-opioids. The in vivo significance of κ-opioid signaling of P. aeruginosa was demonstrated in mice by showing that dynorphin is released from the intestinal mucosa following ischemia/reperfusion injury, activates quinolone signaling in P. aeruginosa, and enhances the virulence of P. aeruginosa against Lactobacillus spp. and Caenorhabditis elegans. Taken together, these data demonstrate that P. aeruginosa can intercept opioid compounds released during host stress and integrate them into core elements of quorum sensing circuitry leading to enhanced virulence. Precisely how bacterial pathogens such as Pseudomonas aeruginosa cause fatal infections in critically ill humans is unknown. Evidence suggests that a major source of infection may be the patient's own intestinal microflora, which is subjected to unusual environmental conditions during critical illness. Here, we show that intestinal P. aeruginosa can be alerted to the presence of a physiological disturbance in its host by dynorphin, a human morphine-like chemical released during severe stress. Exposure of P. aeruginosa to dynorphin activates its virulence machinery to produce harmful toxins and to suppress the growth of probiotic bacteria, which are known to promote intestinal health. The molecular mechanisms of these events involve the activation of highly regulated virulence machinery in Pseudomonas, called quorum sensing, that allows bacteria to sense host stress and respond with enhanced harmfulness. These observations suggest that opportunistic pathogens like P. aeruginosa are equipped with sophisticated surveillance systems that take advantage of a weakened host by intercepting and responding to naturally occurring host chemicals that are normally used as signaling molecules for immune activation and analgesia. Elucidation of the effect of dynorphin on Pseudomonas exposes a major mechanism by which this organism behaves as a true opportunist.
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Affiliation(s)
- Olga Zaborina
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Francois Lepine
- Institut National de la Recherche Scientifique (INRS)–Institut Armand-Frappier, Laval, Quebec, Canada
| | - Gaoping Xiao
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Vesta Valuckaite
- Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Yimei Chen
- Department of Biochemistry and Molecular Biology, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Terry Li
- Department of Immunohistochemistry, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Mae Ciancio
- Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Alex Zaborin
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Elaine Petroff
- Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Jerrold R Turner
- Department of Pathology, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Laurence G Rahme
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Eugene Chang
- Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - John C Alverdy
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States of America
- * To whom correspondence should be addressed. E-mail:
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Karakan T, Ergun M, Dogan I, Cindoruk M, Unal S. Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fiber supplementation versus standard enteral solution: A prospective randomized double-blind study. World J Gastroenterol 2007; 13:2733-7. [PMID: 17569144 PMCID: PMC4147124 DOI: 10.3748/wjg.v13.i19.2733] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the beneficial effects of early enteral nutrition (EN) with prebiotic fiber supplementation in patients with severe acute pancreatitis (AP).
METHODS: Thirty consecutive patients with severe AP, who required stoppage of oral feeding for 48 h, were randomly assigned to nasojejunal EN with or without prebiotics. APACHE II score, Balthazar’s CT score and CRP were assessed daily during the study period.
RESULTS: The median duration of hospital stay was shorter in the study group [10 ± 4 (8-14) d vs 15 ± 6 (7-26) d] (P < 0.05). The median value of days in intensive care unit was also similar in both groups [6 ± 2 (5-8) d vs 6 ± 2 (5-7) d]. The median duration of EN was 8 ± 4 (6-12) d vs 10 ± 4 (6-13) d in the study and control groups, respectively (P > 0.05). Deaths occurred in 6 patients (20%), 2 in the study group and 4 in the control group. The mean duration of APACHE II normalization (APACHE II score < 8) was shorter in the study group than in the control group (4 ± 2 d vs 6.5 ± 3 d, P < 0.05). The mean duration of CRP normalization was also shorter in the study group than in the control group (7 ± 2 d vs 10 ± 3 d, P < 0.05).
CONCLUSION: Nasojejunal EN with prebiotic fiber supplementation in severe AP improves hospital stay, duration nutrition therapy, acute phase response and overall complications compared to standard EN therapy.
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Affiliation(s)
- Tarkan Karakan
- Gazi University Faculty of Medicine, Department of Gastroenterology, Ankara, Turkey.
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Flidel-Rimon O, Branski D, Shinwell ES. The fear of necrotizing enterocolitis versus achieving optimal growth in preterm infants--an opinion. Acta Paediatr 2006; 95:1341-4. [PMID: 17062457 DOI: 10.1080/08035250600719713] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
UNLABELLED Very-low-birthweight (VLBW) infants suffer marked growth delay despite well-intentioned efforts at combining enteral and parenteral nutrition. Fear of necrotizing enterocolitis (NEC) has traditionally influenced neonatologists toward delaying and progressing slowly with enteral feeding, while supporting the infant with parenteral nutrition. Current evidence suggests significant benefits of enteral feeding that is started early and advanced at rates of 20-35 ml/kg/d. CONCLUSION We conclude that fear of inadequate growth should replace the fear of NEC in guiding nutritional strategies for these infants.
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Shimizu T, Tadokoro R, Kaneko N, Suzuki M, Tanaka K, Shinohara K, Shiga S, Yamashiro Y. Effects of extremely early enteral feeding on plasma glicentin levels in very-low-birthweight infants. J Paediatr Child Health 2006; 42:636-9. [PMID: 16972972 DOI: 10.1111/j.1440-1754.2006.00941.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Glicentin, an active component of enteroglucagon, is considered to have a significant trophic action on the intestinal mucosa. We examined the effects of extremely early enteral feedings on the postnatal and postprandial changes in plasma glicentin levels in very-low-birthweight (VLBW) infants. METHODS We measured the plasma glicentin concentrations before and after feedings at 1 or 2 days, 5 or 6 days and 14 days after birth in 21 VLBW infants. The subjects were randomly divided into an extremely early feeding group, which was started on breast milk within 24 h after birth, and a control group, which was started on breast milk more than 24 h after birth. RESULTS Plasma basal concentrations of glicentin at 5 or 6 days and at 14 days after birth were significantly higher than those at 1 or 2 days after birth in the early feeding group. The basal glicentin level at 14 days after birth was significantly higher than that at 1 or 2 days. The basal levels at 5 or 6 days and at 14 days after birth in the early feeding group were significantly higher than those in the control group. Plasma glicentin concentrations after feeding were significantly higher than those before feeding at 5 or 6 days and 14 days after birth in the early feeding group, but those levels were significantly higher only at 14 days after birth in the control group. CONCLUSION Our results suggest that extremely early enteral feedings may play an important role in the development of glicentin secretion and intestinal mucosal growth in the early period of life in VLBW infants.
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Affiliation(s)
- Toshiaki Shimizu
- Department of Pediatrics, Juntendo University, School of Medicine, Tokyo, Japan.
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Abstract
PURPOSE The purpose of this review is to describe the clinical presentation and pathophysiology of stress-related mucosal bleeding and review the strategies to prevent bleeding. SUMMARY The mortality rate associated with clinically significant stress-related mucosal bleeding is high. Respiratory failure requiring mechanical ventilation for more than 48 hours and coagulopathy are two strong, independent risk factors for bleeding. Splanchnic hypoperfusion is the underlying etiology of stress-related mucosal injury and bleeding. Mucosal damage typically manifests as multiple superficial lesions without perforation, and bleeding often originates in superficial capillaries after the patient is admitted to the intensive care unit. Providing adequate visceral perfusion is vital to preventing bleeding. Gastrointestinal function should be taken into consideration before using enteral nutrition, and enteral nutrition should not be the sole stress ulcer prophylactic therapy. Acid-suppression therapy should be used to raise the intragastric pH above 3.5 because it reduces the incidence of stress-related mucosal bleeding. Proton pump inhibitors are at least as effective, and may be more effective than histamine H2-receptor antagonists in achieving this pH goal and preventing bleeding. CONCLUSION The key to reducing mortality from stress-related bleeding in critically ill patients is to prevent mucosal damage. Providing adequate visceral perfusion and acid-suppression therapy can reduce the risk of stress-related mucosal damage and bleeding.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, BIW-442, Medical College of Georgia, Augusta, GA 30912, USA.
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Mick DJ, Ackerman MH. Critical care nursing for older adults: pathophysiological and functional considerations. Nurs Clin North Am 2004; 39:473-93. [PMID: 15331298 DOI: 10.1016/j.cnur.2004.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aging of the population brings into health care practice, including ICUs, an increasing prevalence of people with chronic conditions with corresponding expectations of eventual decline in function. These age-related health problems, however, do not have a precise moment of onset, nor a single and unambiguous cause. By their nature, chronic conditions do not have an end that can be modified easily, and ordinarily, they are related to parameters other than physiology alone. Aged individuals often are distinguished as a medicalized cohort on the basis of sheer numbers of comorbidities and predisposition toward frequent hospitalizations, without regard for the potential for adaptation to life despite complex health factors. Some care providers, health economists, and bioethicists propose using the existence of chronic conditions and assumed physical decompensation asa valid basis for restricting individuals and groups, by means of rationing, from consideration for intensive care and treatment. In view of studies demonstrating that covert rationing of ICU resources to critically ill older patients already is taking place, there isa need to continue to examine institutional policies that permit care providers to act as gatekeepers, ostensibly with benign intent, but presumably without patients' knowledge or acceptance. On the other hand, there is evidence that older ICU patients do equally well as younger and middle-aged patients in terms of discharge from the hospital with subsequent recovery of function. Thus, age alone is not a useful marker for limiting access to ICUs. Rather, a comprehensive evaluation is the foundation for diagnostic accuracy and health care decision-making for older individuals. Assessment and maintenance of the older person's functional status are fundamental concerns of geriatric and critical care specialists. Evaluation of an individual's baseline abilities in physical, mental, social, and psychological spheres is necessary before limitation of care realistically can be considered. Intensive care unit hospitalizations for catastrophic or critical illness are not necessarily terminal events. Ongoing functional assessment will help to illuminate the impact of chronicity on an older person's capacity for self care, and may help to guide health care decision-making regarding use of critical care resources. Accordingly, assuring equitable access to essential intensive care services, devoid of concerns about age constraints, will help to ensure the autonomy that is central to older adults' achievement of a fulfilling and productive old age.
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Affiliation(s)
- Diane J Mick
- Gerontological Nurse Practitioner Program and Center for Clinical Research on Aging, University of Rochester School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642-8404, USA.
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Flidel-Rimon O, Friedman S, Lev E, Juster-Reicher A, Amitay M, Shinwell ES. Early enteral feeding and nosocomial sepsis in very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2004; 89:F289-92. [PMID: 15210657 PMCID: PMC1721698 DOI: 10.1136/adc.2002.021923] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The interrelations between early enteral feeding, necrotising enterocolitis (NEC), and nosocomial sepsis (NS) remain unclear. OBJECTIVE To evaluate the effect of age at the introduction of enteral feeding on the incidence of NS and NEC in very low birthweight (VLBW< 1500 g) infants. METHODS Data were collected on the pattern of enteral feeding and perinatal and neonatal morbidity on all VLBW infants born in one centre during 1995-2001. Enteral feeding was compared between infants with and without NS and/or NEC. RESULTS The study sample included 385 infants. Of these, 163 (42%) developed NS and 35 (9%) developed NEC. Enteral feeding was started at a significantly earlier mean (SD) age in infants who did not develop nosocomial sepsis (2.8 (2.6) v 4.8 (3.7) days, p = 0.0001). Enteral feeding was introduced at the same age in babies who did or did not develop NEC (3.1 (2) v 3.7 (3) days, p = 0.28). Over the study period, the mean annual age at the start of enteral feeding fell consistently, and this correlated with the mean annual incidence of NS (r(2) = 0.891, p = 0.007). Multiple logistic regression analysis showed age at start of enteral feeding, respiratory distress syndrome, and birth weight to be the most significant predictors of risk of NS (p = 0.0005, p = 0.024, p = 0.011). CONCLUSIONS Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC in VLBW infants. These findings support the use of early enteral feeding in this high risk population, but this needs to be confirmed in a large randomised controlled trial.
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Rosário HS, Waldo SW, Becker SA, Schmid-Schönbein GW. Pancreatic trypsin increases matrix metalloproteinase-9 accumulation and activation during acute intestinal ischemia-reperfusion in the rat. THE AMERICAN JOURNAL OF PATHOLOGY 2004; 164:1707-16. [PMID: 15111317 PMCID: PMC1615674 DOI: 10.1016/s0002-9440(10)63729-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/26/2004] [Indexed: 12/21/2022]
Abstract
Ischemia-reperfusion of the intestine produces a set of inflammatory mediators, the origin of which has recently been shown to involve pancreatic digestive enzymes. Matrix metalloproteinase-9 (MMP-9) participates in a variety of inflammatory processes including myocardial, hepatic, and pancreatic ischemia-reperfusion. In the present study, we explore the role of neutrophil-derived MMP-9 in acute intestinal ischemia-reperfusion and its interaction with pancreatic trypsin. Male Sprague-Dawley rats were subjected to 45 minutes of superior mesenteric arterial occlusion followed by 90 minutes of reperfusion. In situ zymography of the proximal jejunum reveals increased gelatinase activity in the intestinal wall after ischemia-reperfusion. Gel electrophoresis zymography and immunofluorescence co-localization suggests that this gelatinase activity is derived from MMP-9 released from infiltrating neutrophils. The role of intraluminal trypsin in this process was investigated using an in vivo isolated jejunal loop model of intestinal ischemia-reperfusion. Trypsin increased the inflammatory response after reperfusion, with an augmented neutrophil infiltration of the intestinal wall. Furthermore, trypsin stimulated a rapid conversion of neutrophil-released proMMP-9 into the lower molecular weight enzymatically active MMP-9. This process represents a powerful in vivo pathophysiological mechanism for trypsin-induced MMP-9 activation and is likely to play a central role in the development of acute intestinal inflammation and shock.
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Affiliation(s)
- Henrique S Rosário
- Department of Bioengineering, The Whitaker Institute for Biomedical Engineering, University of California San Diego, La Jolla, California 92093, USA
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Abstract
Closer attention to the clear liquid diet and its therapeutic applications has been prompted by critical reviews of nutritional enhancement in the clinical environment. The aim of ongoing research has been to uncover the optimal nutrient complement in various patient groups as well as the most beneficial mode of nutrient delivery. Route of feeding is often the essential determinant in effectiveness of nutritional support. Many studies have sought to demonstrate the superiority of enteral versus parenteral nutrition, whereas comparative studies with clear liquid diets are sparse. Recently, identification of key nutrients in the support of malnourished or immunocompromised patients has been emphasized. Although total parenteral nutrition has undisputed applications in specific patient groups, it has lost favor for general application because of its negative impact on immunocompetence. Efforts have thus been redoubled to explore the potential of the gastrointestinal tract, with the derived benefit in immunosupport for many medical and surgical disease states. Until recently, the clear liquid diet had not received close scrutiny and had retained an unchallenged position in certain applications (eg, bowel preparation). This paper summarizes the published, theorized, and potential benefits as well as the limitations of the clear liquid diet.
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Affiliation(s)
- Susan Hancock
- Department of Surgery, Medical College of Georgia, 1120 15th Street, Room 4072, Augusta, GA 30912, USA
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