[DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version]. / DGEM-Leitlinie: Klinische Ernährung in der Intensivmedizin ­ Kurzversion.

PURPOSE: Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function. METHODS: The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process. RESULTS: The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices. CONCLUSION: The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).

[Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]. / Laborchemisches und kalorimetrisches Monitoring der medizinischen Ernährungstherapie auf der Intensiv- und Intermediate Care Station : Zweites Positionspapier der Sektion Metabolismus und Ernährung der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).

This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.

[Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]. / Erfassung und apparatives Monitoring des Ernährungsstatus von Patient*innen auf der Intensiv- und Intermediate Care Station : Positionspapier der Sektion Metabolismus und Ernährung der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).

At the time of admission to an intensive or intermediate care unit, assessment of the patients' nutritional status may have both prognostic and therapeutic relevance with regard to the planning of individualized medical nutrition therapy (MNT). MNT has definitely no priority in the initial treatment of a critically ill patient, but is often also neglected during the course of the disease. Especially with prolonged length of stay, there is an increasing risk of malnutrition with considerable prognostic macro- and/or micronutrient deficit. So far, there are no structured, evidence-based recommendations for assessing nutritional status in intensive or intermediate care patients. This position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) presents consensus-based recommendations for the assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units. These recommendations supplement the current S2k guideline "Clinical Nutrition in Intensive Care Medicine" of the German Society for Nutritional Medicine (DGEM) and the DIVI.

Ascorbic Acid in postoperative intensive care patients - biochemical aspects and clinical experience.

The transport mechanisms of ascorbic acid (AA) are described. The metabolism of AA and its function as an antioxidant are covered in some detail. Subsequently, indications for postoperative substitution are discussed. The supplementation of up to 300 mg of AA per day in postoperative intensive care unit patients during par-/enteral nutrition is recommended to prevent hypovitaminosis. It is not clear if this is the optimal dosage of AA in postoperative/-trauma patients. New aspects for an AA substitution are discussed.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM).

PURPOSE: Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS: The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS: In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION: The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Ascorbic acid reduces noise-induced nitric oxide production in the guinea pig ear.

OBJECTIVES: Noise-induced hearing loss can be caused, among other causes, by increased nitric oxide (NO) production in the inner ear leading to nitroactive stress and cell destruction. Some studies in the literature suggest that the degree of hearing loss (HL) could be reduced in an animal model through ascorbic acid supplementation. To identify the effect of ascorbic acid on tissue-dependent NO content in the inner ear of the guinea pig, we determined the local NO production in the organ of Corti and the lateral wall separately 6 hours after noise exposure. STUDY DESIGN: Prospective animal study in guinea pigs. METHODS: Over a period of 7 days, male guinea pigs were supplied with minimum (25 mg/kg body weight/day) and maximum (525 mg/kg body weight/day) ascorbic acid doses, and afterwards exposed to noise (90 dB sound pressure level for 1 hour). The acoustic-evoked potentials were recorded before and after noise exposure. The organ of Corti and the lateral wall were incubated differently for 6 hours in culture medium, and the degree of NO production was determined by chemiluminescence. RESULTS: Ascorbic acid treatment reduced the hearing threshold shift after noise exposure depending on concentration. When the maximum ascorbic acid dose was substituted, NO production was significantly reduced in the lateral wall after noise exposure and slightly reduced in the organ of Corti. CONCLUSIONS: Oral supplementation of the natural radical scavenger ascorbic acid reduces the NO-production rate in the inner ear in noisy conditions. This finding supports the concept of inner ear protection by ascorbic acid supplementation.

Postoperative analgesic efficacy of peripheral levobupivacaine and ropivacaine: a prospective, randomized double-blind trial in patients after total knee arthroplasty.

BACKGROUND: Several previous trials have characterized the intra- and postoperative effects of the recently introduced local anesthetics, levobupivacaine and ropivacaine, for a variety of continuous peripheral nerve blocks. METHODS: We compared the analgesic efficacy of levobupivacaine 0.125% versus ropivacaine 0.2% via patient-controlled femoral nerve analgesia after total knee arthroplasty. In a double-blind, randomized, prospective design, 60 patients received femoral infusion with either substance. We analyzed postoperative local anesthetic consumption, pain scores, motor block, and opioid requirements over 72 h. RESULTS: Pain scores, motor block incidence, and opioid requirements were low and not different between the groups. Ropivacaine consumption in milligrams was 67% higher than that of levobupivacaine. CONCLUSIONS: Both levobupivacaine 0.125% and ropivacaine 0.2% provide similar analgesia after total knee arthroplasty with the latter being less potent.

Early postoperative substitution procedure of the antioxidant ascorbic acid.

BACKGROUND: Postoperatively reduced concentration of ascorbic acid (AA) in plasma (< or =45.5 micromol/l (< or =800 microg/dl)) is commonly interpreted as increased metabolic requirements, but it is not shown yet that the patient benefits from a substitution toward normal levels of AA. This is due to the missing knowledge on how to substitute AA effectively to normal plasma values in postoperative patients. Therefore, a postoperative AA substitution procedure "overnight" to normal values in plasma was investigated on a postoperative intensive care unit (ICU) in a university hospital. MATERIAL AND METHODS: Fifty-seven operated patients were randomly assigned to a control- or intervention group (CG and IG, respectively). In all patients, the AA plasma concentration was analysed preoperatively and on the first three postoperative days. Patients of the IG received AA intravenously up to four times within 12 h depending upon the initial AA concentration (<34.1 micromol/l (4x500 mg AA); < or =56.8 micromol/l (2x500 mg AA); < or =68.2 micromol/l (1x500 mg AA)). RESULTS: The preoperative and early postoperative AA values did not differ between the groups. On the first postoperative day in both groups the plasma concentration was lowered (< or =45.5 micromol/l) in 23 of all patients (CG: 85.18%; IG: 82.14%). In the IG, the dosage regime increased the AA plasma concentration to > or =45.5 micromol/l in 26 of 28 (92.86%) patients overnight. CONCLUSION: The investigated substitution procedure is sufficient to increase AA plasma concentration overnight to normal or high normal values in postoperative ICU patients.

Determination of alpha-tocopherol in plasma by high performance liquid chromatography with fluorescence detection and stability of alpha-tocopherol under different conditions.

In order to study the clinical effects of the antioxidant alpha-tocopherol (tocofersolan, CAS 30999-06-5) a simple, robust, sensitive and reliable high performance liquid chromatography (HPLC) method using fluorescence detection for the daily measurement of alpha-tocopherol concentration in plasma is described. Several methods of HPLC analysis using fluorescence techniques are published, however, investigations of the stability of alpha-tocopherol during sample preparation under different conditions are relevant in the routine measurements and have to date not been reported. Therefore a modified method, both sensitive and robust, qualified for the day-by-day measurement of alpha-tocopherol in plasma was established and the stability of alpha-tocopherol during sample preparation was analysed under different conditions. This method enables the complete separation of alpha-tocopherol from other compounds within 14 min. In addition, investigations on the stability of alpha-tocopherol during sample preparation showed the necessity of rapid sample preparation without delay. Prepared samples can be stored in liquid nitrogen for at least 56 days.

Ceftazidime determination in serum by high-pressure liquid chromatography.

A rapid and sensitive high-pressure liquid chromatographic method with simple sample preparation was developed for the quantitative analysis of the beta-lactam antibiotic ceftazidime (CAS 78439-06-2, Fortum). A good linear relationship was established between the peak area and the amount of ceftazidime injected over a concentration range of 1 to 200 microg/ml. The detection limit of the method was calculated to be 0.9 microg/ml. Stability was shown at 4 degrees C and at -196 degrees C for time periods of 2 h and 84 days, respectively.

Clearance of ascorbic acid in plasma in patients before major maxillofacial surgery compared with that in volunteers.

Reduced concentration of ascorbic acid (AA) in plasma is often observed in tumor patients. Besides malnutrition, an increased AA consumption in tumor patients is discussed as a main reason for reduced AA concentration in plasma. A reduced AA concentration caused by malnutrition would not influence the total clearance (Cltot) of AA in plasma; however, a change in AA consumption would alter the Cltot. To investigate this further, a study was carried out on 20 patients hospitalized for major maxillofacial surgery and 20 volunteers. The Cltot of AA in plasma after bolus injection of AA (4 mg/kg body wt) in tumor patients was compared with that in volunteers. AA concentration in plasma (P < 0.05) was significantly lower in tumor patients (median and 25th and 75th percentiles: 23.7, 14.6, and 32.7 mumol/l) than in volunteers (median and 25th and 75th percentiles: 66.5, 59.6, and 78.6 mumol/l). No significant change in Cltot was observed for tumor patients (median and 25th and 75th percentiles: 11.5, 8.0, and 14.0 l/h) compared with volunteers (median and 25th and 75th percentiles: 11.3, 9.9, and 13.2 l/h). No indication of an increased consumption of AA in tumor patients could be detected. The lowered concentration of AA in plasma observed in our patients might be the result of a reduced AA intake.