Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study.

BACKGROUND: Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort. METHODS: The 'French-Speaking ICU Nutritional Survey' (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses. RESULTS: During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23-2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00-1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01-1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98-1.11). CONCLUSIONS: In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk. Trial registration ClinicalTrials.gov Identifier: NCT02599948. Retrospectively registered on November 5th 2015.

Role of gut microbiota and bacterial translocation in acute intestinal injury and mortality in patients admitted in ICU for septic shock.

Introduction: Sepsis is a life-threatening organ dysfunction with high mortality rate. The gut origin hypothesis of multiple organ dysfunction syndrome relates to loss of gut barrier function and the ensuing bacterial translocation. The aim of this study was to describe the evolution of gut microbiota in a cohort of septic shock patients over seven days and the potential link between gut microbiota and bacterial translocation. Methods: Sixty consecutive adult patients hospitalized for septic shock in intensive care units (ICU) were prospectively enrolled. Non-inclusion criteria included patients with recent or scheduled digestive surgery, having taken laxatives, pre- or probiotic in the previous seven days, a progressive digestive neoplasia, digestive lymphoma, chronic inflammatory bowel disease, moribund patient, and pregnant and lactating patients. The primary objective was to evaluate the evolution of bacterial diversity and richness of gut microbiota during seven days in septic shock. Epidemiological, clinical and biological data were gathered over seven days. Gut microbiota was analyzed through a metagenomic approach. 100 healthy controls were selected among healthy blood donors for reference basal 16S rDNA values. Results: Significantly lower bacterial diversity and richness was observed in gut microbiota of patients at Day 7 compared with Day 0 (p<0.01). SOFA score at Day 0, Acute Gastrointestinal Injury (AGI) local grade, septic shock origin and bacterial translocation had an impact on alpha diversity. A large increase in Enterococcus genus was observed at Day 7 with a decrease in Enterobacterales, Clostridiales, Bifidobacterium and other butyrate-producing bacteria. Discussion: This study shows the importance of bacterial translocation during AGI in septic shock patients. This bacterial translocation decreases during hospitalization in ICUs in parallel to the decrease of microbiota diversity. This work highlights the role of gut microbiota and bacterial translocation during septic shock.

Monocyte human leukocyte antigen-DR but not ß-D-glucan may help early diagnosing invasive Candida infection in critically ill patients.

BACKGROUND: Precision medicine risk stratification is desperately needed to both avoid systemic antifungals treatment delay and over prescription in the critically ill with risk factors. The aim of the present study was to explore the combination of host immunoparalysis biomarker (monocyte human leukocyte antigen-DR expression (mHLA-DR)) and Candida sp wall biomarker ß-D-glucan in risk stratifying patients for secondary invasive Candida infection (IC). METHODS: Prospective observational study. Two intensive care units (ICU). All consecutive non-immunocompromised septic shock patients. Serial blood samples (n = 286) were collected at day 0, 2 and 7 and mHLA-DR and ß-D-glucan were then retrospectively assayed after discharge. Secondary invasive Candida sp infection occurrence was then followed at clinicians' discretion. RESULTS: Fifty patients were included, 42 (84%) had a Candida score equal or greater than 3 and 10 patients developed a secondary invasive Candida sp infection. ICU admission mHLA-DR expression and ß-D-glucan (BDG) failed to predict secondary invasive Candida sp infection. Time-dependent cause-specific hazard ratio of IC was 6.56 [1.24-34.61] for mHLA-DR < 5000 Ab/c and 5.25 [0.47-58.9] for BDG > 350 pg/mL. Predictive negative value of mHLA-DR > 5000 Ab/c and BDG > 350 pg/mL combination at day 7 was 81% [95% CI 70-92]. CONCLUSIONS: This study suggests that mHLA-DR may help predicting IC in high-risk patients with septic shock. The added value of BDG and other fungal tests should be regarded according to the host immune function markers.

Exercise and Nutrition Strategies to Counteract Sarcopenic Obesity.

As the population is aging rapidly, there is a strong increase in the number of individuals with chronic disease and physical limitations. The decrease in skeletal muscle mass and function (sarcopenia) and the increase in fat mass (obesity) are important contributors to the development of physical limitations, which aggravates the chronic diseases prognosis. The combination of the two conditions, which is referred to as sarcopenic obesity, amplifies the risk for these negative health outcomes, which demonstrates the importance of preventing or counteracting sarcopenic obesity. One of the main challenges is the preservation of the skeletal muscle mass and function, while simultaneously reducing the fat mass in this population. Exercise and nutrition are two key components in the development, as well as the prevention and treatment of sarcopenic obesity. The main aim of this narrative review is to summarize the different, both separate and combined, exercise and nutrition strategies so as to prevent and/or counteract sarcopenic obesity. This review therefore provides a current update of the various exercise and nutritional strategies to improve the contrasting body composition changes and physical functioning in sarcopenic obese individuals.

Nutrition rehabilitation in the intensive care unit.

The maintenance of homeostasis after severe injury requires the restoration of the physiological regulation of food intake. A wide array of functional alterations can hinder the intake of adequate amounts of nutrients to support the recovery from critical illness. These alterations encompass changes in the preprandial phase, reflected by a loss of appetite; changes in the prandial phase, yielding swallowing disorders; and changes in the postprandial phase, including impairments of gastric emptying, gut motility, and satiety. This tutorial aims to review these often overlooked features and to suggest recommendations for the nutrition rehabilitation of the critically ill.

Volume expansion in the first 4 days of shock: a prospective multicentre study in 19 French intensive care units.

PURPOSE: To describe the current practices of volume expansion in French intensive care units (ICU). METHODS: In 19 ICUs, we prospectively observed the prescription and monitoring practices of volume expansion in consecutive adult patients with shock [sustained hypotension and/or need of vasopressor therapy, associated with at least tachycardia and/or sign (s) of hypoperfusion]. Patients were included at the time of prescription of the first fluid bolus (FB). Thereafter, all the FBs administered during the 96 h following shock onset were surveyed. An FB was defined as an intravenous bolus of at least 100 ml of a blood volume expander intended to rapidly improve the patient's circulatory condition. RESULTS: We included 777 patients [age: 63 ± 15 years; female gender: 274 (35 %); simplified acute physiology score II: 55.9 ± 20.6; ICU length of stay: 6 days (interquartile range (IQR) 3-13); ICU mortality: 32.8 %] and surveyed 2,694 FBs. At enrolment mean arterial pressure was 63 mmHg (IQR 55-71). The most frequent triggers of FB were hypotension, low urine output, tachycardia, skin mottling and hyperlactataemia. Amount of fluid given at each FB was highly variable between centres. Crystalloids were used in 91 % (2,394/2,635) and synthetic colloids in 3.3 % (87/2,635) of FBs. Overall, clinicians used any kind of haemodynamic assessment (central venous pressure measurement, predictive indices of fluid responsiveness, echocardiography, cardiac output monitoring or a combination of these) in 23.6 % (635/2,694) of all FBs surveyed, with an important between-centre heterogeneity. CONCLUSIONS: High between-centre variability characterised all the aspects of FB prescription and monitoring, but overall haemodynamic exploration to help guide and monitor FB was infrequent.

Outcome of renal transplant recipients admitted to an intensive care unit: a 10-year cohort study.

BACKGROUND: Epidemiology and prognosis of severe complications related to renal transplantation requiring admission to intensive care unit (ICU) have not been assessed precisely. This study was undertaken to evaluate the outcome in this population and to identify the factors of prognosis. METHODS: All records of adult renal transplant recipients admitted to our ICU from 1997 to 2007 were reviewed including transplant variables, clinical and biological parameters, use of mechanical ventilation, catecholamine support, or dialysis or both. Mortality was assessed and data were analyzed to identify predictive factors of outcome. RESULTS: Twenty-seven women and 30 men, median age 54 years, were included in the study. Eighteen patients were oliguric, 35 were mechanically ventilated, 32 underwent hemodialysis, and 36 needed catecholamine. Twenty-three patients died (40.3%), a mortality significantly higher than in a matched by age and gravity scores control group of nontransplant ICU patients. By univariate analysis, survivors had a significantly lower ICU severity scores, a higher mean arterial pressure, a higher Glasgow Coma Score, a higher serum albumin, and a lower serum lactate on ICU admission. The need for catecholamine support, mechanical ventilation or dialysis or both during the ICU stay worsens the outcome significantly. Using the multivariate analysis, only the mean arterial pressure and the need for mechanical ventilation were predictive of mortality. CONCLUSION: The incidence of severe transplant-related complications requiring an admission to an ICU was at 16 of 1000 patients year with a mortality rate higher than the general ICU population (40% vs. 20%). These data suggest that immunosuppressive treatment of transplant patients with severe complications worsens significantly their outcome.

Caracteristicas clinico-epidemiologicas de la diarrea aguda del adulto en un hospital de la ciudad de Cordoba / Clinical and epidemiologic characteristics of acute diarrhea of the adult in a hospital from Cordoba city

El objetivo de este estudio fue observar las principales características clínicas y epidemiológicas de la presentación de la diarrea aguda del adulto en un hospital público de la ciudad de Córdoba. Para su realización se incluyeron todos los pacientes mayores de 14 años que concurrieron a la Guardia Central del Hospital Nacional de Clínicas con diarrea aguda durante los períodos A(15-12-89 al 15-3-90), B(15-12-93 al 15-3-94), y C(15-12-94 al 15-3-95). El total de pacientes incluídos en los 3 períodos fue de 594: 337 mujeres (65,7 por ciento) y 257 varones; 143 consultaron en el período A, 250 en el B y 201 en el C. El promedio + DE de edad fue 34,6 + 13,3 años y de deposiciones diarias al momento de la consulta 7,3 + 4,7. El 86,1 por ciento presentó materia fecal de consistencia líquida durante el pisodio, 89,6 por ciento dolor abdominal, 44,7 por ciento vómitos y 18,8 por ciento sangre. El porcentaje de pacientes que concurrieron al hospital por diarrea aguda en relación al total de consultas aumentó del período A (2,47 por ciento) al B (3,61 por ciento), p=0,002 y disminuyó del período B al C(2,85 por ciento), p=0,01. Los promedios + DE de días transcurridos desde el inicio del cuadro hasta la consulta fueron 3,5 + 2,7 + 2,3 y 2,9 + 3,5 en los períodos A, B y C, diferencia estadísticamente significativa entre A y B, p<0,01. Presentó moco en la material fecal el 36,2 por ciento, 21.1 por ciento y 23,1 por ciento de los pacientes en los períodos A, B y C (p=0,01) y fiebre constatada el 61,1 por ciento, 48,1 por ciento y 48,5 por ciento respectivamente (p=0,04). El 27.1 por ciento de los coprocultivos resultó positivo en el período A, 17,6 por ciento en el B y 11,5 por ciento en el C; diferencia entre a y C: p=0,008. Se concluye que en un hospital público de la ciudad de Córdoba la diarrea aguda del adulto es causa frecuente de consulta, constatándose modificaciones de las características clínico-epidemiológicas en los ultimos años.

Caracteristicas clinico-epidemiologicas de la diarrea aguda del adulto en un hospital de la ciudad de Cordoba / Clinical and epidemiologic characteristics of acute diarrhea of the adult in a hospital from Cordoba city

El objetivo de este estudio fue observar las principales características clínicas y epidemiológicas de la presentación de la diarrea aguda del adulto en un hospital público de la ciudad de Córdoba. Para su realización se incluyeron todos los pacientes mayores de 14 años que concurrieron a la Guardia Central del Hospital Nacional de Clínicas con diarrea aguda durante los períodos A(15-12-89 al 15-3-90), B(15-12-93 al 15-3-94), y C(15-12-94 al 15-3-95). El total de pacientes incluídos en los 3 períodos fue de 594: 337 mujeres (65,7 por ciento) y 257 varones; 143 consultaron en el período A, 250 en el B y 201 en el C. El promedio + DE de edad fue 34,6 + 13,3 años y de deposiciones diarias al momento de la consulta 7,3 + 4,7. El 86,1 por ciento presentó materia fecal de consistencia líquida durante el pisodio, 89,6 por ciento dolor abdominal, 44,7 por ciento vómitos y 18,8 por ciento sangre. El porcentaje de pacientes que concurrieron al hospital por diarrea aguda en relación al total de consultas aumentó del período A (2,47 por ciento) al B (3,61 por ciento), p=0,002 y disminuyó del período B al C(2,85 por ciento), p=0,01. Los promedios + DE de días transcurridos desde el inicio del cuadro hasta la consulta fueron 3,5 + 2,7 + 2,3 y 2,9 + 3,5 en los períodos A, B y C, diferencia estadísticamente significativa entre A y B, p<0,01. Presentó moco en la material fecal el 36,2 por ciento, 21.1 por ciento y 23,1 por ciento de los pacientes en los períodos A, B y C (p=0,01) y fiebre constatada el 61,1 por ciento, 48,1 por ciento y 48,5 por ciento respectivamente (p=0,04). El 27.1 por ciento de los coprocultivos resultó positivo en el período A, 17,6 por ciento en el B y 11,5 por ciento en el C; diferencia entre a y C: p=0,008. Se concluye que en un hospital público de la ciudad de Córdoba la diarrea aguda del adulto es causa frecuente de consulta, constatándose modificaciones de las características clínico-epidemiológicas en los ultimos años. (AU)