Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study.

BACKGROUND & AIMS: Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition. METHODS: Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin. RESULTS: Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs -1566 kcal; p = 0.033). There was a one-day reduction in the median duration of fasting in period B (p < 0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p = 0.003) and prealbumin measurement (p < 0.001), the latter increasing significantly more during ICU stay. CONCLUSION: Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.

Acceptation of Folk Medicine and its "secrets" in a Swiss Burn Centre.

In Switzerland 'Secret' is a folk medicine called upon for burns. It has belonged to UNESCO's intangible cultural heritage since 2012. It is supposed to ease pain and accelerate the healing process of burns. As the practice is widely used in the population, this observational study investigated the opinion of caregivers and patients from the National Burn Center of Lausanne. Qualitative observational study based on a survey including ten questions aimed at identifying the professionals' perception of the phenomenon. Questions were developed from repeated encounters in the burn center. Data collection took five months. Thirty-six healthcare professionals (HP) and 12 selected patients (or parents for minors) discharged after burns were interviewed on a voluntary basis: all of the HPs knew about 'Secret' from the workplace, and 26 from home: 33 were convinced that it might be useful and reduce pain. The perceived efficiency of the practice (36 respondents) differs depending on professional category and personal experience. Only one HP considered the practice to be dangerous. The nurses and auxiliary nurses expressed that it should be used more widely. The 12 patients considered it as a complementary step, not a replacement for medical care. Health professionals globally considered this practice safe and helpful. The patients were interested in using parallel approaches and were careful about their expectations. This openness is probably an indication that HPs believe that acceptance of the culture and beliefs of patients and their families might positively affect response to treatment, whatever the burn size.

Il existe en Suisse une médecine traditionnelle dénommée « secret ¼ dédiée aux brûlures (supposée avoir des effets analgésiques et cicatrisants) inscrite au patrimoine immatériel de l'UNESCO depuis 2012. Dans la mesure où elle est très largement utilisée, nous avons conduit une étude observationnelle sur l'opinion qu'en ont les soignants et les patients du CTB national de Lausanne. Nous avons utilisé un questionnaire à dix items, développé après des entretiens plus informels. Trente six professionnels et 12 patients (ou parents quand le patient était mineur), interrogés après leur sortie, ont volontairement participé à l'étude. Tous les professionnels avaient entendu parler de « secret ¼ soit au travail soit chez eux (26). Trente trois étaient persuadés de son utilité analgésique, 1 seul le considérant comme dangereux. Cette opinion varie selon la catégorie professionnelle et l'expérience personnelle, les infirmières et aide- soignantes estimant qu'il devrait être plus largement utilisé. Les patients estimaient que « secret ¼ était un adjuvant ne devant pas remplacer la prise en charge médicalisée. Les professionnels considéraient que « secret ¼ est simple et utile. Les patients étaient intéressée par cette approche parallèle, tout en gardant une certaine retenue quant à ce qu'ils pouvaient en attendre. Cette ouverture d'esprit suggère que les professionnels pensent que la prise en compte de la culture et des croyances des patients et de leur famille peut promouvoir l'efficacité du traitement conventionnel, quelle que soit la surface brûlée.

[Trace element issues in Switzerland and Europe]. / Oligoéléments en Suisse et en Europe.

Essential trace elements are inorganic metalloid substances: insufficient intakes cause predictable biological and clinical alterations. Numerous factors contribute to the alterations of iron, iodine, selenium, and zinc status, such as low soil content resulting in low food content, malabsorption, or biological fluid losses. Age categories at high risk of deficit in the general population include children, pregnant and lactating women, and elderly; critical illness is a specific condition. Substitution and supplementation studies that respect physiological nutritional doses result in significant clinical benefits: improved immunity and cognitive functions, better wound healing. Supplementation with supra-nutritional doses in subjects or patients with adequate status may result in deleterious cancer and cardiovascular consequences due to their potential toxicity.

Fish oil after abdominal aorta aneurysm surgery.

OBJECTIVE: Fish oil (FO) may attenuate the inflammatory response after major surgery such as abdominal aortic aneurysm (AAA) surgery. We aimed at evaluating the clinical impact and safety aspects of a FO containing parenteral nutrition (PN) after AAA surgery. METHODS: Intervention consisted in 4 days of either standard (STD: Lipofundin medium-chain triglyceride (MCT): long-chain triglyceride (LCT)50%-MCT50%) or FO containing PN (FO: Lipoplus: LCT40%-MCT50%-FO10%). Energy target were set at 1.3 times the preoperative resting energy expenditure by indirect calorimetry. Blood sampling on days 0, 2, 3 and 4. Glucose turnover by the (2)H(2)-glucose method. Muscle microdialysis. CLINICAL DATA: maximal daily T degrees, intensive care unit (ICU) and hospital stay. RESULTS: Both solutions were clinically well tolerated, without any differences in laboratory safety parameters, inflammatory, metabolic data, or in organ failures. Plasma tocopherol increased similarly; with FO, docosahexaenoic and eicosapentaenoic acid increased significantly by day 4 versus baseline or STD. To increased postoperatively, with a trend to lower values in FO group (P=0.09). After FO, a trend toward shorter ICU stay (1.6+/-0.4 versus 2.3+/-0.4), and hospital stay (9.9+/-2.4 versus 11.3+/-2.7 days: P=0.19) was observed. CONCLUSIONS: Both lipid emulsions were well tolerated. FO-PN enhanced the plasma n-3 polyunsaturated fatty acid content, and was associated with trends to lower body temperature and shorter length of stay.

Nutritional support during renal replacement therapy.

BACKGROUND/AIMS: Malnutrition is common in critically ill patients with acute renal failure. The aim of this review is to describe the basis for nutritional support during renal replacement therapy. METHODS: Review of the literature. RESULTS: Techniques of nutritional support and nutritional requirements are described. CONCLUSION: Early aggressive enteral, parenteral or combine nutritional support is required in critically ill patients on replacement therapy.

Safety and intestinal tolerance of high-dose enteral antioxidants and glutamine peptides after upper gastrointestinal surgery.

OBJECTIVE: Safety and intestinal tolerance of an early high-dose enteral administration of antioxidative vitamins, trace elements, and glutamine dipeptides. DESIGN: open intervention trial. SETTING: Two university teaching hospitals. PATIENTS: A total of 14 patients requiring jejunal feeding (64+/-14 y). INTERVENTION: A measure of 500 ml/day Intestamin (FreseniusKabi: 250 kcal/1.050 kJ, 300 microg selenium, 20 mg zinc, 400 mug chromium, 1500 mg vitamin C, 500 mg vitamin E, 10 mg beta-carotene, 30 g glutamine) for 5 days beginning 6 h after surgery. Parenteral/enteral nutrition was provided to achieve energy target (25 kcal/kg/day). ASSESSMENTS: Intestinal complaints, plasma nutrients, and glutathione. RESULTS: Only minor signs of nausea, hiccups, flatulence (3/14). Plasma micronutrients (except beta-carotene) postoperatively decreased and increased to normal on day 5. Extracellular glutamine remained low (preop: 520+/-94; d1: 357+/-67; d5: 389+/-79 micromol/l); total glutathione decreased (d1: 9.4+/-3.8; d5: 3.6+/-2.5 micromol/l). CONCLUSION: Study feed is well tolerated and metabolically safe representing a valuable tool for targeted pharmaconutrient supply.

Influence of selenium supplements on the post-traumatic alterations of the thyroid axis: a placebo-controlled trial.

OBJECTIVE: To investigate whether early selenium (Se) supplementation can modify the post-traumatic alterations of thyroid hormone metabolism, since the first week after trauma is characterised by low plasma Se and negative Se balances. DESIGN: Prospective, placebo-controlled randomised supplementation trial. SETTING: Surgical ICU in a tertiary university hospital. PATIENTS: Thirty-one critically ill trauma patients aged 42 +/- 16 years (mean +/- SD), with severe multiple injury (Injury Severity Score 30 +/- 7). INTERVENTION: Supplementation during the first 5 days after injury with either Se or placebo. The selenium group was further randomised to receive daily 500 microg Se, with or without 150 mg alpha-tocopherol (AT) and 13 mg zinc supplements. The placebo group received the vehicle. Circulating Se, AT, zinc, and thyroid hormones were determined on D0 (= day 0, admission), D1, D2, D5, D10, and D20. RESULTS: Plasma Se, low on D0, normalised from D1 in the selenium group; total T4 and T3 increased more and faster after D2 (P = 0.04 and 0.08), reverse T3 rising less between D0 and D2 (P = 0.05). CONCLUSIONS: Selenium supplements increased the circulating Se levels. Supplementation was associated with modest changes in thyroid hormones, with an earlier normalisation of T4 and reverse T3 plasma levels. The addition of AT and zinc did not produce any additional change.

Trace element supplementation modulates pulmonary infection rates after major burns: a double-blind, placebo-controlled trial.

Infections remain the leading cause of death after major burns. Trace elements are involved in immunity and burn patients suffer acute trace element depletion after injury. In a previous nonrandomized study, trace element supplementation was associated with increased leukocyte counts and shortened hospital stays. This randomized, placebo-controlled trial studied clinical and immune effects of trace element supplements. Twenty patients, aged 40 +/- 16 y (mean +/- SD), burned on 48 +/- 17% of their body surfaces, were studied for 30 d after injury. They consumed either standard trace element intakes plus supplements (40.4 micromol Cu, 2.9 micromol Se, and 406 micromol Zn; group TE) or standard trace element intakes plus placebo (20 micromol Cu, 0.4 micromol Se, and 100 micromol Zn; group C) for 8 d. Demographic data were similar for both groups. Mean plasma copper and zinc concentrations were below normal until days 20 and 15, respectively (NS). Plasma selenium remained normal for group TE but decreased for group C (P < 0.05 on days 1 and 5). Total leukocyte counts tended to be higher in group TE because of higher neutrophil counts. Proliferation to mitogens was depressed compared with healthy control subjects (NS). The number of infections per patient was significantly (P < 0.05) lower in group TE (1.9 +/- 0.9) than in group C (3.1 +/- 1.1) because of fewer pulmonary infections. Early trace element supplementation appears beneficial after major burns; it was associated with a significant decrease in the number of bronchopneumonia infections and with a shorter hospital stay when data were normalized for burn size.

Trace elements in trauma and burns.

This review describes the place of trace elements in the management of critically ill injured patients. There has been a growing interest in trace elements as a result of their essential role in endogenous antioxidant defence mechanisms and in immunity. Burns and trauma are associated with increased free radical production and negative trace element balances, which contribute to the imbalance in endogenous antioxidant capacity and the extension of primary lesions. Supplementation trials have shown that early provision of large amounts of trace elements improve recovery after major burns and brain injury.

Exudative mineral losses after serious burns: a clue to the alterations of magnesium and phosphate metabolism.

Hypomagnesemia and hypophosphatemia are frequent after severe burns; however, increased urinary excretion does not sufficiently explain the magnitude of the mineral depletion. We measured the mineral content of cutaneous exudates during the first week after injury. Sixteen patients aged 34 +/- 9 y (mean +/- SD) with thermal burns were studied prospectively and divided in 3 groups according to the extent of their burn injury and the presence or absence of mineral supplements: group 1 (n = 5), burns covering 26 +/- 5% of body surface; group 2 (n = 6), burns covering 41 +/- 10%; and group 3 (n = 5), burns covering 42 +/- 6% with prescription of magnesium and phosphate supplements. Cutaneous exudates were extracted from the textiles (surgical drapes, dressings, sheets, etc) surrounding the patients from day 1 to day 7 after injury. Mean magnesium serum concentrations decreased below reference ranges in 12 patients between days 1 and 4 and normalized thereafter. Phosphate, normal on day 0, was low during the first week. Albumin concentrations, normal on day 0, decreased and remained low. Urinary magnesium and phosphate excretion were within reference ranges and not larger in group 3. Mean daily cutaneous losses were 16 mmol Mg/d and 11 mmol P/d (largest in group 2). Exudative magnesium losses were correlated with burn severity (r = 0.709, P = 0.003). Cutaneous magnesium losses were nearly four times larger than urinary losses whereas cutaneous phosphate losses were smaller than urinary phosphate losses. Mean daily losses of both magnesium and phosphate were more than the recommended dietary allowances. Exudative losses combined with urinary losses largely explained the increased mineral requirements after burn injury.

Relations between the selenium status and the low T3 syndrome after major trauma.

OBJECTIVE: Thyroxine (T4) is deiodinated to triiodothyronine (T3) by the hepatic type I iodothyronine deiodinase, a selenoprotein that is sensitive to selenium (Se) deficiency. After severe injury, T4 deiodination is decreased, leading to the low T3 syndrome. Injury increases free radical production, which inactivates the iodothyronine deiodinase. The aims were to study the Se status after major trauma and to investigate its relation to the low T3 syndrome. DESIGN: Preliminary prospective descriptive study. SETTING: Intensive care unit at a university teaching hospital. PATIENTS AND METHODS: 11 patients aged 41 +/- 4 years (mean +/- SEM), with severe multiple injuries (Injury Severity Score 29 +/- 2 points). A balance study was performed from day 1 to day 7. Serum and urine samples were collected from the time of admission until day 7, then on days 10, 15, 20, 25 and 30. Non-parametric tests and Pearson's correlation coefficients were used for analysis. RESULTS: Cumulated Se losses were 0.88 +/- 0.1 mumol/24h. Serum Se was decreased from admission to day 7. T3, free T3, and the T3/T4 ratio were low until day 5, being lowest on day 2; T4 and thyroid stimulating hormone were normal. Serum Se was correlated with T3 (r = 0.55, p = 0.0001), and with free T3 (r = 0.35). CONCLUSION: Se status is altered after trauma, with decreased Se serum levels upon admission to the ICU but with no major Se losses. Se is probably redistributed to the tissues. The correlation between Se and T3, along with the parallel decrease in T4 deiodination, indicates that reduced deiodination might be related to the transient decrease in serum Se.

Copper, selenium, and zinc status and balances after major trauma.

To investigate the trace elements (TE) losses and status after trauma, 11 severely injured patients (Injury Severity Score: 29 +/- 6), admitted to the ICU were studied from the day of injury (D0) until D25. Balance studies were started within 24 hours after injury, until D7. Serum and urine samples were collected from D1 to D7, then on D10, 15, 20, and 25. Intravenous TE supplementation was initiated upon admission. SERUM: Selenium (Se) and zinc (Zn) levels were decreased until D7 and were normal thereafter. LOSSES: TE urinary excretions were higher than reference ranges until D20 in all patients. Fluid losses through drains contained large amounts of TE. BALANCES: Balances were slightly positive for copper (Cu) and Zn, and negative for Se from D5 to D7 despite supplements. Cu status exhibited minor changes compared to those observed with the Zn and Se status: Serum levels were decreased and losses increased. Considering the importance of Se and Zn in free radical scavenging, anabolism, and immunity, current recommendations for TE supplements in severely traumatized patients ought to be revised.

Relations between copper, zinc and selenium intakes and malondialdehyde excretion after major burns.

Copper, zinc and selenium are involved in free radical scavenging. As trace element status is altered after major burns, related free radical scavenging may be decreased: consequently lipid peroxidation, reflected by increased urinary malondialdehyde excretion (MDA), is considerably increased. This preliminary study aimed to investigate the relationship between trace elements and MDA excretion. Sixteen patients aged 34 +/- 9 years (mean +/- s.d.) burned over 37 +/- 11 per cent of body surface, were studied prospectively. Trace element balance studies from days 1 to 7 and serum and urine concentrations on days 10, 15, 20 and 25 were measured. The first 11 patients (groups 1--SBU < 80, and 2--SBU > or = 80) were given standard supplements and the five next patients increased supplements (group 3, SBU > or = 80). The MDA excretion from days 1 to 3 was correlated with burn severity (r = 0.59). The correlations between serum trace element levels after day 3 and MDA were negative: Cu, r = -0.065; Zn, r = -0.52; Se, r = -0.53. In Group 3, MDA excretion after day 3 decreased with increasing cumulative Zn (r = -0.46) and Se intakes (r = -0.57). It can be concluded that the MDA decrease after day 3 was not clearly attributable to the trace element supplements, but the negative trend observed between Zn and Se supplements and decreased MDA excretion requires further studies.

[Role of trace elements and vitamins in peri-operative nutrition]. / Rôle des oligo-éléments et des vitamines en nutrition périopératoire.

The micronutriment requirements, whether trace elements (inorganic) or vitamins (organic), are tightly linked to the carbohydrate, lipid and protein metabolism, since they are involved in all metabolic pathways as cofactors. The micronutriments also have major immunological, endocrinological and antioxydant functions. Especially in the surgical patient, individual requirements may vary considerably and will be particularly increased in case of prior deficiency, anabolic states, or increased losses (burns, diarrhoea, gastric aspiration, intestinal fistulae, alcoholism, use of renal replacement techniques). In some of these settings, the micronutriment requirements will be independent from the macronutriments: this has been demonstrated for burns and intestinal fistulae. In the case of depletion prior to surgery, an isolated supplementation may be required without starting a proper nutrition. In general, micronutriment supplements will have to be started upon initiation of any artificial nutrition. After elective surgery and in absence of specific losses, the micronutriment requirements will be linked to the metabolic state of the patient and to the energy-protein intakes. This is most striking for the vitamin B group, where the requirements are indicated in mg per 1000 kcal. Vitamins A and E are also at risk in the surgical patient. Recommended micronutriment supplements have been revised in 1994. Some trace element deficiencies (Se, Cr, Mo) can initiate very serious complications and will require special caution in the perioperative period. Other deficiencies (Cu, Zn) result in more slowly evolving clinical pictures, with lesser life-threatening potential, resulting in infections and prolonged wound healing. In such cases, multi-elementary supplements are inadequate, and single element solutions supplements are required. All the micronutriments are characterized by a dose-response curve. The quantity avoiding biochemical dysfunctioning in human pathological situations has not yet been established, and it is unsatisfactory to merely compensate for the losses. This notion of biochemical dysfunctioning phase preceeding the clinical deficiency syndrome is in investigation for many nutriments, especially as the importance of some micronutriments, such as Se and vitamin E, in maintaining antioxidant defences is clearly established. The potential for preventing free radical induced overproduction of cytokines by means of nutritional strategy and enhanced antioxidant defences clearly exists, and is only at an early phase of investigation in patients. The future will be marked by the development of nutritional pharmacology based on pathology-specific micronutriment supplements.

Influence of large intakes of trace elements on recovery after major burns.

Because Cu, Se, and Zn are involved in immune and antioxidative defense mechanisms and tissue repair, deficiencies might aggravate complications classically observed with burns. After measuring massive cutaneous trace element losses in 10 burn patients, our aim in this study was to determine whether large intravenous intakes of Cu, Zn, and Se can modify serum trace element levels and recovery after major burns. Ten patients, aged 34 +/- 6 yr (mean +/- SD), admitted to the burns center of a Swiss university hospital with thermal burns on 41 +/- 9% of their body surface were studied prospectively, with trace element balance studies from day 1 (D1) to D7 postinjury. Urine and blood samples were also collected on D10, D15, D20, and D25. The patients were divided into two groups of five and received either standard (group 1, control) or greatly increased (group 2, treatment: 4.5 mg Cu, 190 micrograms Se, and 40 mg Zn/day) trace element intakes. Energy and protein intake and wound treatment were similar in both groups. The treatment group was characterized by improved Cu, Se, and Zn status (increase in serum levels and various protein indicators), a much larger leukocyte increase between D4 and D14 (mainly neutrophils), and shorter hospital stay (45 days) compared with the untreated group (57 days). Grafting requirements were more extensive in group 1. Although severity of injury and wound treatment were similar in the groups, the duration of hospitalization was lower in the treated group. Further studies are required to determine whether this is related to trace element supplementation.

[Unrecognised intake of trace elements in polytraumatized and burnt patients]. / Apports méconnus d'oligo-éléments chez les polytraumatisés et les grands brûlés.

Recommended trace element doses during parenteral nutrition have been revised many times and increased, especially in surgical patients. Blood products are known to provide significant amounts of trace elements under certain circumstances. In intensive care patients crystalloids and colloids are also given in large amounts. This study aimed at determining the magnitude of the unrecognized trace element administrations after major burns and/or trauma. Fifteen patients burnt 36 +/- 11% (mean +/- SD) of body surface area, aged 34 +/- 8 years, admitted to the Burns Centre and 11 trauma patients with an Injury Severity Score of 29 +/- 6 points, aged 40 +/- 13 years, admitted to the surgical Intensive Care Unit in a Swiss University Hospital. Prospective study of intakes and urinary excretion from the first post-injury day (D1) to D7. Copper and zinc were analyzed by flame atomic absorption spectrophotometry, and selenium by fluorimetry. The actual trace element administrations were much larger than those prescribed in the 3 groups of patients, and were significantly above the most recent parenteral recommended daily allowance = RDA (2.3 times RDA for copper, 5 times for selenium and zinc in Group 2, which received the largest i.v. supplements). There greatest provision of the 3 elements was by the blood products (packed red cells and frozen plasma) and by the albumin solutions (0.5 mg.L-1 Cu, 90 micrograms.L-1 Se and 2.1 mg.L-1 Zn in the 20% solutions). During the resuscitation phase, crystalloids provided a significant amount of copper (0.14 mg.L-1 NaCl 0.9%, none in dextrose) and zinc (0.3 mg.L-1 of any crystalloid), whereas selenium was not detected.(ABSTRACT TRUNCATED AT 250 WORDS)