Nutritional and metabolic characteristics of critically ill patients admitted for severe toxidermia.

INTRODUCTION: Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU. METHOD: Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital. INCLUSION CRITERIA: Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia. VARIABLES: severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median [IQR]. RESULTS: Altogether 35 patients were included (27 SJS/TEN and 8 "other"), aged 58 [48; 69] years. Skin involvement was 45% [30; 60] of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 [6.5; 26] days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 [89; 218] mg/L). The first 2 weeks' energy and protein intakes were below recommendations (p < 0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 [23.9; 35.5] kcal/kg) resulting in negative energy balances (mean -245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding. CONCLUSION: Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube. CLINICALTRIALS: gov Identifier: NCT05320653.

Computer customization errors compromised the optimization of trace element repletion dose after major burns.

BACKGROUND & AIMS: Major burns develop acute trace element (TE) deficiencies due to exudative losses of copper, selenium, and zinc from the wounds. A repletion strategy has been shown to decrease infectious and surgical complications. The TE doses have been adapted over time and the last adaptation, was not followed by the expected changes. The study aims at identifying the causes of the failure. METHODS: Retrospective cohort study including critically ill major burns patients admitted to intensive care with burns exceeding 20% of body surface area (BSA). Period A (2011-2015) included patients admitted before the dose change, and Period B patients after (2017-2020). Demographic variables, daily TE delivery, and weekly TE blood levels were extracted from the computerized information system (CIS). RESULTS: Altogether 71 patients completed the inclusion criteria (Periods A and B: 42 and 29 patients respectively). They were aged 38 (32) years and burned 35 (30) % BSA, with no severity differences. Comparing periods A and B, copper (p = 0.046) and selenium (p = 0.031) blood levels were significantly lower in B. The dose value extracted from CIS was as planned. Customization error was found: TE salts' weight had been entered instead of elemental weight in molar units. CONCLUSION: The lower TE repletion doses administered since 2017 resulted in a significant decrease in blood levels of Cu and Se. A CIS customisation error, confusing salt weight and elemental weight was the source of the error. A systematic quality control is crucial to identify systemic errors, as is the use of the standard international units.

Specific nutrition and metabolic characteristics of critically ill patients with persistent COVID-19.

BACKGROUND: Little is known about metabolic and nutrition characteristics of patients with coronavirus disease 2019 (COVID-19) and persistent critical illness. We aimed to compare those characteristics in patients with PCI and COVID-19 and patients without COVID-19 infection (non-CO)-primarily, their energy balance. METHODS: This is a prospective observational study including two consecutive cohorts, defined as needing intubation for >10 days. We collected demographic data, severity scores, nutrition variables, length of stay, and mortality. RESULTS: Altogether, 104 patients (52 per group) were included (59 ± 14 years old [mean ± SD], 75% men) between July 2019 and May 2020. SAPSII, Nutrition Risk Screening (NRS) score, proportion of obese patients, duration of intubation (18.2 ± 11.7 days), and mortality rates were similar. Patients with COVID-19 (vs non-CO) had lower SOFA scores (P = 0.013) and more frequently needed prone position (P < 0.0001) and neuromuscular blockade (P < 0.0001): lengths of ICU (P = 0.03) and hospital stays were shorter (P < 0.0001). Prescribed energy targets were below those of the ICU protocol. The energy balance of patients with COVID-19 was significantly more negative after day 10. Enteral nutrition (EN) started earlier (P < 0.0001). During the first 10 days, COVID-19 patients received more lipid (propofol sedation) and less protein. Higher admission C-reactive protein (P = 0.002) decreased faster (P < 0.001). Whereas intestinal function was characterized by constipation in both groups during the first 10 days, diarrhea was less common in patients with COVID-19 thereafter. CONCLUSION: Compared with non-CO patients, COVID-19 patients were not more obese, had lower SOFA scores, and were fed more rapidly with EN, because of a more normal gastrointestinal function possibly due to fewer non-respiratory organ failures: their energy balances were more negative after the first 10 days. Propofol sedation reduced protein delivery.

Exudative glutamine losses contribute to high needs after burn injury.

BACKGROUND: Burnpatients characteristically have increased energy, glucose, and protein requirements. Glutamine supplementation is strongly recommended during early-phase treatment and is associated with improved immunity, wound healing, and reduced mortality. This study evaluated if early burn exudative losses might contribute to higher supplementation needs. METHODS: Patients admitted to the burn intensive care unit (ICU) had exudate collection from tight bandages applied to arms or legs during the first week (exudate aliquot twice daily). Seven amino acids (alanine, arginine, cystEine, glutamine, leucine, lysine, and methionine) were quantified by liquid chromatography-mass spectrometry. Descriptive analysis of all results is provided as median and interquartile range or in value ranges. RESULTS: Eleven patients aged 19-77 years, presenting with burns on 18%-70% of the body surface, with a median simplified acute physiology score II of 33 (range, 16-56) were included during the study period. The highest amino acid losses were observed during the first 3 days with an important interpatient and intrapatient variability. Glutamine and alanine losses were highest, followed by leucine and lysine in all patients; amino acid exudate concentrations were in the range of normal plasma concentrations and were stable over time. Total glutamine losses were correlated to the burned surface (r2 = 0.552, P = .012), but not to enteral glutamine supplements. CONCLUSIONS: The study shows significant exudative losses during early-stage burn recovery and particularly for glutamine and alanine. Glutamine loss generally decreased with wound closure, the subsequent decline of exudation, and the evolving size of burn surfaces.

Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients.

BACKGROUND: insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor. METHODS: analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay. STATISTICS: parametric and non-parametric tests. RESULTS: 150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older (p = 0.024), tended to have a higher SAPSII score (p = 0.072), with a significantly higher NRS score (p = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU's protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; p = 0.038). Higher protein delivery was associated with an increase in prealbumin over time (r2 = 0.19, p = 0.027). CONCLUSIONS: High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.

Trace element repletion following severe burn injury: A dose-finding cohort study.

BACKGROUND & AIMS: Major burn patients are characterized by large exudative losses of Cu, Se and Zn. Trace element (TE) repletion has been shown to improve clinical outcome. Having increased the TE doses over time, the study aimed at analysing if our repletion protocol corrected TE plasma concentrations and if the necessity for continuous renal replacement therapy (CRRT) might increase the TE needs. METHODS: Retrospective analysis of prospectively collected data in burn patients requiring intensive care (ICU) between 1999 and 2015. INCLUSION CRITERIA: Admission on day 1, full treatment, burned surface area (TBSA) ≥20% and ≥1 TE plasma determination during the stay. Four groups were constituted according to protocol changes. Period 1 (P1): 1999-2000, P2: 2001-2005, P3: 2006-2010, P4: 2011-2015. Changes consisted in increasing TE repletion doses and duration. Demographic data, daily TE intakes and weekly plasma concentrations were retrieved for the first 21 ICU-days. Data as median (IQR). RESULTS: 139 patients completed the criteria, aged 37 (28) years, burned on 35 (25) % TBSA. As a result of prescription, Cu, Se and Zn intakes increased significantly between P1 and P4, resulting in normalization of plasma Cu (16 µmol/l) since P3 and Zn (13.5 µmol/l) since P2. Median plasma Se were above reference range (1400 nmol/l) during P3 and P4. CRRT patients required higher doses of Cu for maintenance within normal ranges. CONCLUSION: This dose finding study shows that the latest repletion protocol is safe and normalizes Cu and Zn concentrations. Se doses result in supra-normal Se concentrations, suggesting prescription reduction. CRRT patients are at high risk of Cu depletion and require specific monitoring.

Supplemental parenteral nutrition improves immunity with unchanged carbohydrate and protein metabolism in critically ill patients: The SPN2 randomized tracer study.

BACKGROUND & AIMS: Individualized supplemental parenteral nutrition (SPN) providing measured energy expenditure from day 4 reduced infectious complications in a previous study including 305 intensive care (ICU) patients. The study aimed at investigating the metabolic, and immune responses underlying the clinical response of the previous trial. METHODS: Randomized controlled trial enrolling 23 critically ill patients on day 3 (D3) of admission to the ICU who were fed less than 60% of their energy target by the enteral nutrition (EN) alone: allocation to either continued EN or to SPN to a target validated by indirect calorimetry. Protein and glucose metabolism (primary endpoint) were investigated with tracer isotopes on D4 and D9. Secondary endpoints: 1) immune response, investigated in serum and in stimulated peripheral blood mononuclear cells (PMBC), by dosing a panel of cytokines (infectious complications were recorded), and 2) Muscle mass was assessed by ultrasound of the thigh. RESULTS: Comparable at baseline, the SPN group (n = 11) received more energy (median 24.3 versus 17.8 kcal/kg/day: p < 0.001) and proteins (1.11 versus 0.69 g/kg/day: p < 0.001) than the control group during the five days' intervention, resulting in a less negative energy balance by D9 (p = 0.0027). Net protein breakdown and Glucose kinetics on D9 did not differ, within or between groups. In agreement with a decrease in infection rate, immune response in the SPN group showed decreased serum IL-6 (p = 0.024), IL-1ß, IL-10 levels and TNF-α secretion by PBMC (p = 0.018) at D9. Muscle mass loss from D4 to D15 tended to be less in the SPN group (-16% versus -23%: p = 0.06). Clinical course by D28 did not differ. CONCLUSIONS: Feeding patients to cover an individualised measured energy target with SPN from D4 to cover needs, was associated with improved immunity, less systemic inflammation and a trend to less muscle mass loss. CLINICAL TRIAL REGISTRY: NCT02022813 at https://clinicaltrials.gov/.

Propofol sedation substantially increases the caloric and lipid intake in critically ill patients.

OBJECTIVE: The amount of lipid delivered to patients varies considerably depending on the non-nutritional intake from sedation, and on the feeding solution. The aim of this study was to quantify the magnitude and proportion of lipids and energy provided from propofol sedation in intensive care unit (ICU) patients. METHODS: This was a retrospective analysis of prospectively collected data in consecutive patients admitted to the ICUs of two university hospitals. Inclusion criterion included an ICU stay >5 d. Data were collected for a maximum of 10 d. Propofol sedation using 1% or 2% propofol solutions was defined as >100 mg/d. Nutritional management was per protocol in both centers, recommending enteral feeding. Data are shown as means ± standard deviation. RESULTS: In all, 701 admissions (687 patients, ages 59 ± 16 y, SAPS II 51 ± 17) and 6485 d, including 3484 propofol sedation days were analyzed. Energy targets were 1987 ± 411 kcal/d; mean energy delivery was 1362 ± 811 kcal/d (70% ± 38% of prescription) including propofol and dextrose. Enteral feeding dominated (75% of days) and progressed similarly in both ICUs. Mean propofol sedation dose was 2045 ± 1650 mg/d, resulting in 146 ± 117 kcal/d. Fat from propofol constituted 17% of total energy (up to 100% during the first days). Fat delivery (40 ± 23 g/d: maximum 310 g/d) was significantly increased by the combination of propofol sedation, the 1% solution, and high-fat-containing feeds. In survivors, high-fat proportion was associated with prolonged ventilation time (P < 0.0001). CONCLUSION: Propofol sedation resulted in large doses of lipids being delivered to patients, some receiving pure lipids during the first days. As the metabolic effects of high proportions of fat are unknown, further research is warranted.

Massive copper and selenium losses cause life-threatening deficiencies during prolonged continuous renal replacement.

OBJECTIVE: Several trace elements are essential for immunity and wound healing, particularly after major burns. Continuous renal replacement therapy (CRRT), which is used to treat renal failure, causes significant trace elements losses. The aim of the present review is to update the current literature and draw attention to this type of complication, as copper deficiency is rarely suspected and diagnosed in clinical conditions and may occur in chronic critically ill patients. METHODS: This is an emblematic case report and review of literature. RESULTS: Major copper and selenium deficiencies were documented in a patient with major burns complicated by renal failure. The main cause was effluent loss during prolonged CRRT. The copper deficit resulted in life-threatening bradycardia and the alteration of lipid metabolism with severe hypertriglyceridemia. The published data are scarce, but trace element losses with effluent have been previously documented, as has the affect of copper deficiency on cardiac rhythm. CONCLUSION: The literature regarding the specific requirements for chronically critically ill patients is limited. During prolonged CRRT, copper and selenium levels decrease and probably should be monitored during prolonged therapy. Research in this area is required.