Real-time continuous glucose monitoring in an intensive care unit: better accuracy in patients with septic shock.

OBJECTIVE: This study assessed the accuracy of real-time continuous glucose monitoring system (RTCGMS) devices in an intensive care unit (ICU) to determine whether the septic status of the patient has any influence on the accuracy of the RTCGMS. SUBJECTS AND METHODS: In total, 41 patients on insulin therapy were included. Patients were monitored for 72 h using RTCGMS. Arterial blood glucose (ABG) samples were obtained following the protocol established in the ICU. The results were evaluated using paired values (excluding those used for calibration) with the performance assessed using numerical accuracy. Nonparametric tests were used to determine statistically significant differences in accuracy. RESULTS: In total, 956 ABG/RTCGMS pairs were analyzed. The overall median relative absolute difference (RAD) was 13.5%, and the International Organization for Standardization (ISO) criteria were 68.1%. The median RADs reported for patients with septic shock, with sepsis, and without sepsis were 11.2%, 14.3%, and 16.3%, respectively (P<0.05). Measurements meeting the ISO criteria were 74.5%, 65.6%, and 63.7% for patients with septic shock, with sepsis, and without sepsis, respectively (P<0.05). CONCLUSIONS: The results showed that the septic status of patients influenced the accuracy of the RTCGMS in the ICU. Accuracy was significantly better in patients with septic shock in comparison with the other patient cohorts.

The effect of L-alanyl-L-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients.

OBJECTIVE: The aim of this study was to assess the clinical efficacy of alanine-glutamine dipeptide-supplemented total parenteral nutrition defined by the occurrence of nosocomial infections. Secondary parameters included Sequential Organ Failure Assessment score, hyperglycemia and insulin needs, intensive care unit and hospital length of stay, and 6-month mortality. DESIGN: Multicenter, prospective, double-blind, randomized trial. SETTING: Twelve intensive care units at Spanish hospitals. PATIENTS: One hundred twenty-seven patients with Acute Physiology and Chronic Health Evaluation II score >12 and requiring parenteral nutrition for 5-9 days. INTERVENTION: Patients were randomized to receive an isonitrogenous and isocaloric total parenteral nutrition or alanine-glutamine dipeptide-supplemented total parenteral nutrition. Nutritional needs were calculated: 0.25 g N/kg(-1)/d(-1) and 25 kcal/kg(-1)/d(-1). The study group received 0.5 g/kg(-1)/d(-1) of glutamine dipeptide and the control total parenteral nutrition group a similar amount of amino acids. Hyperglycemia was controlled applying an intensive insulin protocol with a target glycemia of 140 mg/dL. MEASUREMENTS AND MAIN RESULTS: The two groups did not differ at inclusion for the type and severity of injury or the presence of sepsis or septic shock. Caloric intake was similar in both groups. Preprotocol analysis showed that treated patients with alanine-glutamine dipeptide-supplemented total parenteral nutrition had lesser nosocomial pneumonia, 8.04 vs. 29.25 episodes-‰ days of mechanical ventilation (p = .02), and urinary tract infections, 2.5 vs. 16.7 episodes-‰ days of urinary catheter (p = .04). Intensive care unit, hospital, and 6-month survival were not different. Mean plasmatic glycemia was 149 ± 46 mg/dL in the alanine-glutamine dipeptide-supplemented total parenteral nutrition group and 155 ± 51 mg/dL in the control total parenteral nutrition group (p < .04), and mean hourly insulin dose was 4.3 ± 3.3 IU in the alanine-glutamine dipeptide-supplemented total parenteral nutrition group and 4.7 ± 3.7 IU in control total parenteral nutrition group (p < .001). Multivariate analysis showed a 54% reduction of the amount of insulin for the same levels of glycemia in the alanine-glutamine dipeptide-supplemented total parenteral nutrition group. CONCLUSIONS: Total parenteral nutrition supplemented with alanine-glutamine in intensive care unit patients is associated with a reduced rate of infectious complications and better glycemic control.

Caloric intake and liver dysfunction in critically ill patients.

PURPOSE OF REVIEW: Despite increasing evidence that critically ill patients have lower energy requirements than expected, most guidelines continue to recommend elevated caloric requirements in these patients, particularly in septic patients. This practice leads to liver dysfunction when artificial nutrition is employed and worsens the prognosis of these patients. This review is focused on recent developments in the pathogenesis of artificial nutrition associated liver dysfunction in critically ill patients. RECENT FINDINGS: The liver plays a pivotal role in managing nutritional substrates, and it is involved in the inflammatory response to injury and sepsis. The landmark phenomenon is insulin resistance and changes in the metabolic fates of glucose and fat. Glucose and lipids can act as toxics synergistically with inflammation to induce liver dysfunction. There are experimental evidences that insulin resistance in critically ill patients can share the same biochemical mechanisms and metabolic fates involved in insulin resistance of type 2 diabetes mellitus and metabolic syndrome. Furthermore, steatosis is also a common feature in both clinical pictures SUMMARY: The pathogenesis of artificial nutrition associated with liver dysfunction is related to overfeeding and sepsis with a pathophysiology, similar to metabolic syndrome and type 2 diabetes. Changing nutritional strategies and adding new drugs will prevent, in part, liver dysfunction in these patients.

Liver dysfunction associated with artificial nutrition in critically ill patients.

INTRODUCTION: Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients. METHODS: We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l. RESULTS: Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05). CONCLUSION: TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Safety and metabolic tolerance of a concentrated long-chain triglyceride lipid emulsion in critically ill septic and trauma patients.

BACKGROUND: A concentrated fat emulsion (Intralipid 30%) with a phospholipid/triglyceride ratio of 0.04 was tested for clinical tolerance and metabolic effects in the short-term parenteral nutrition of septic and trauma critically ill patients and compared with Intralipid 20% (phospholipid/triglyceride ratio of 0.06). METHODS: This was a prospective, randomized, multicenter study in the intensive care units in 10 university hospitals, including 90 adult patients in 2 groups: 55 septic and 35 trauma patients. Patients in each group were randomly divided into 2 subgroups according to the fat emulsions administered (1.4 g/kg per day) as part of the calories for at least 6 days of continuous total parenteral nutrition (TPN). One subgroup was treated with 30% long-chain triglycerides (phospholipid/ triglyceride ratio: 0.04) and the other with 20% long-chain triglycerides (phospholipid/triglyceride ratio: 0.06). The parenteral nutrition formula was isocaloric and isonitrogenous with 0.25 g of nitrogen/kg per day and 40% of the nonprotein calories as fat. Clinical tolerance was assessed during the study. At baseline and after 3 and 6 days of TPN, the following biochemical parameters were measured: prealbumin, retinol-binding protein, serum albumin, hematologic, hepatic and renal function variables, triglycerides, phospholipids, total and free cholesterol, nonesterified cholesterol, nonesterified fatty acids, and lipoproteins. RESULTS: At baseline, no differences in age, gender, severity of the condition [Acute Physiology and Chronic Health Evaluation (APACHE II) score], or clinical chemistry were found between the subgroups. The levels of plasma proteins studied and the renal, hematologic, or hepatic function variables did not vary during the study period. Total cholesterol increased significantly, owing to esterified cholesterol, with 20% long-chain triglyceride in septic patients (baseline: 2.1 +/- 0.8 mmol/L, day 6: 2.8 +/- 0.6 mmol/L, p = .026). In septic patients receiving 20% long-chain triglycerides, plasma triglycerides had a similar behavior (baseline: 1.4 +/- 0.6 mmol/L, day 3: 2.2 +/- 0.8 mmol/L, p < .05). The very-low-density lipoprotein content of cholesterol, triglycerides, and phospholipids showed a tendency to decrease in septic patients treated with 30% long-chain triglycerides (NS). None of the emulsions induced the synthesis of lipoprotein X. CONCLUSIONS: Our results indicate that while both fat emulsions used in the TPN of critically ill patients are clinically safe, the 30% long-chain triglyceride fat emulsion with a phospholipid/triglyceride ratio of 0.04 causes fewer lipid metabolic disturbances.

Effect of a glutamine-enriched enteral diet on intestinal permeability and infectious morbidity at 28 days in critically ill patients with systemic inflammatory response syndrome: a randomized, single-blind, prospective, multicenter study.

We investigated the effect of a glutamine-enriched enteral diet on intestinal permeability and infectious morbidity and mortality in critically ill patients who developed systemic inflammatory response syndrome after an acute event. Eleven intensive care units in tertiary-care hospitals participated in a prospective, randomized, single blind, multicenter trial. Eighty-four patients with systemic inflammatory response syndrome of any etiology were randomly allocated to receive a glutamine-enriched enteral diet or a control diet without glutamine.Most patients received the planned caloric intake. The number of infected patients was smaller in the glutamine group than in the control group (11 versus 17 patients, P < 0.05), with a relative risk of 0.5 (95% confidence interval = 0.3-0.9). The most frequent infection was nosocomial pneumonia, with 11 (33%) patients in the control group and 6 (14%) in the glutamine group. There were no differences with respect to other infections, mortality, or length of stay. Intestinal permeability as assessed by the lactulose-mannitol test was unchanged in both groups.Glutamine-enriched enteral diets can decrease nosocomial infections in patients with systemic inflammatory response syndrome.