Nutrition therapy in the intensive care unit during the COVID-19 pandemic: Findings from the ISIIC point prevalence study.

BACKGROUND & AIMS: Nutrition therapy for Intensive Care Unit (ICU) patients involves complex decision-making, especially during the COVID-19 pandemic. We investigated the use of nutrition therapy in ICU patients with and without COVID-19 infections. METHODS: Nutrition therapy was evaluated during a world-wide one-day prevalence study focused on implementation of the ABCDEF bundle (A: regular pain assessment, B: both spontaneous awakening and breathing trials, C: regular sedation assessment, D: regular delirium assessment, E: early mobility and exercise, and F: family engagement and empowerment) during the COVID-19 pandemic. Basic ICU and patient demographics including nutrition therapy delivery were collected on the survey day. Physical activity for patients with and without COVID infections was categorized using the ICU mobility scale (IMS). Multivariable regression analysis of nutrition was conducted using ICU parameters. RESULTS: The survey included 627 non-COVID and 602 COVID patients. A higher proportion of COVID-19 patients received energy ≥20 kcal/kg/day (55% vs. 45%; p = 0.0007) and protein ≥1.2 g/kg/day (45% vs. 35%; p = 0.0011) compared to non-COVID patients. Enteral nutrition was provided to most COVID patients even with prone positioning (91%). Despite nutrition therapy, IMS was extremely low in both groups; median IMS was 1 in non-COVID patients and 0 in COVID patients. The rate of energy delivery ≥20 kcal/kg/day was significantly higher in patients with COVID-19 infections in the subgroup of ICU days ≤5 days and IMS ≤2. Having a dedicated ICU nutritionist/dietitian was significantly associated with appropriate energy delivery in patients both with and without COVID-19 infections, but not with protein delivery. CONCLUSION: During the COVID-19 pandemic, patients with COVID-19 infections received higher energy and protein delivery. Generally low mobility levels highlight the need to optimize early mobilization with nutrition therapy in all ICU patients.

Acute pancreatitis followed by retroperitoneal perforation of the descending colon and a duodenal fistula: Report of a case.

INTRODUCTION: There are several reports of colon perforation in patients with acute pancreatitis, but the mechanism is not understood. We describe a patient with acute pancreatitis followed by retroperitoneal perforation of the descending colon and a duodenal fistula. CASE PRESENTATION: A 51-year-old male presented with acute pancreatitis. He was hemodynamically unstable, had respiratory failure on admission and was treated in the intensive care unit (ICU). He recovered and left the ICU on day 13. Although his general condition improved, a computed tomography (CT) scan showed air and fluid in the left retroperitoneum. Gastrografin enema and CT scan showed extraluminal leakage in the descending colon and retroperitoneal drainage was performed on day 27. After drainage, there was continuous voluminous feculent discharge, and a loop ileostomy was performed on day 34. A repeat CT scan revealed ascites. A percutaneous catheter injected with contrast showed a duodenal fistula. After drainage, the fever resolved and the patient was discharged on hospital day 106. DISCUSSION: Although there is no clear mechanism of colonic perforation in patients with acute pancreatitis, one hypothesis is that ischemia secondary to inflammation caused by pancreatitis plays a role. The involved area is usually in the watershed areas of the colon. Retroperitoneal drainage of the colon perforation may have necessitated creation of a diverting loop ileostomy. CONCLUSION: Retroperitoneal colon perforation must be considered in patients with acute pancreatitis.

[Primary Small Bowel Tumor with Simultaneous Lung Metastases from Rectal Cancer - A Case Report].

A 56-year-old woman was diagnosed with rectal cancer and liver metastases(Stage IV), and underwent low anterior resection and laparoscopic partial hepatectomy. The patient received adjuvant chemotherapy(mFOLFOX6 for 24 weeks), but developed multiple lung metastases 11 months later. Before undergoing a pulmonary resection, the patient presented with acute small bowel obstruction. Abdominal computed tomography showed small bowel stenosis due to a tumor, and we suspected peritoneal metastases from the rectal tumor. We performed partial resection of the small intestine, and histopathological examination revealed a primary small bowel tumor. The patient was discharged to her home without complications, and later underwent pulmonary resections for bilateral lung metastases. We usually suspect that small bowel obstruction is due to peritoneal metastases in patients with advanced colorectal tumors, but must consider the rare possibility of a separate primary small bowel tumor, especially in patients with a solitary lesion. We report a rare primary small bowel tumor after FOLFOX treatment in a patient with Stage IV rectal cancer.

Japanese Herbal Kampo Hochu-Ekki-To or Juzen-Taiho-To after Surgery for Hip Fracture Does Not Reduce Infectious Complications.

BACKGROUND: Infectious complications after hip fracture surgery are common in the elderly. Although experimental studies have suggested that kampo medicine, Hochu-ekki-to and Juzen-taiho-to, can prevent infectious complications, only a few small clinical studies have been published to date. PRIMARY STUDY OBJECTIVE: The aim of the present study is to investigate the impact of Hochu-ekki-to or Juzen-taiho-to on postoperative infectious complications in patients undergoing surgery for hip fracture. METHODS AND DESIGN: In this retrospective cohort study using a nationwide inpatient database in Japan, we performed propensity score matching to compare patients who did or did not receive kampo medicine after surgery for hip fracture. SETTINGS: A nationwide inpatient database. PARTICIPANTS: Patients who did or did not receive kampo medicine after surgery for hip fracture. INTERVENTION: Kampo medicine after surgery for hip fracture. PRIMARY OUTCOME MEASURES: Infectious complications. RESULTS: The proportions of postoperative infectious complications were not significantly different between the 424 propensity-matched pairs with and without kampo medicine (11 versus 8, P = 0.644). CONCLUSION: The present study suggests that Hochu-ekki-to or Juzen-taiho-to postoperatively is not associated with decreased occurrence of infectious complications in patients who underwent surgery for hip fracture.

Total gastrectomy-induced reductions in food intake and weight are counteracted by rikkunshito by attenuating glucagon-like peptide-1 elevation in rats.

BACKGROUND: Decrease in appetite and weight after total gastrectomy in patients with gastric cancer leads to a decrease in quality of life, increased mortality, and may necessitate discontinuation of adjuvant chemotherapy. The aim of this study is to determine whether rikkunshito, a Japanese herbal medicine, increases food intake and weight after gastrectomy in rats. METHODS: Male rats underwent gastrectomy followed by roux-en-Y reconstruction or sham operation and were then treated with rikkunshito for 14 days starting on postoperative day 3. Daily food intake, weight, plasma glucagon-like peptide-1 (GLP-1), and ghrelin levels were measured. A pilot study to measure pre- and postoperative plasma GLP-1 levels was conducted in patients who underwent total gastrectomy for gastric cancer. RESULTS: Administration of rikkunshito after gastrectomy in rats significantly increased food intake and weight, which continued for at least 2 weeks after treatment. Both fasting and postprandial plasma GLP-1 levels were increased markedly after gastrectomy compared with sham-operated animals. Increased GLP-1 levels in rats after gastrectomy were suppressed markedly by rikkunshito. rikkunshito had no significant effect on plasma ghrelin levels after gastrectomy. Treatment with a GLP-1 receptor antagonist significantly improved food intake and weight after gastrectomy. Plasma fasting GLP-1 levels in patients with gastric cancer were increased greatly after gastrectomy on postoperative day 1. CONCLUSION: Administration of rikkunshito suppresses plasma GLP-1 levels after total gastrectomy, which is associated with recovery from reduced food intake and weight in rats.