Measurement of the thickness of the adductor pollicis muscle as a predictor of outcome in critically ill patients.

OBJECTIVE: Malnutrition is associated with complications and prolonged hospital stay in critically ill patients. We assessed whether the measurement of the thickness of the adductor pollicis muscle (TAPM), a new tool to assess malnutrition is a valuable prognostic indicator in critically ill patients. METHODS: Open cohort study including 248 patients admitted for either medical or surgical intensive care treatment in a tertiary hospital. Two were discharged for having age below 18 years-old and therefore 246 subjects of both sexes completed the entire analysis. Subjective global assessment and APACHE II scores were used to score the patients. TAPM of both hands was measured at admission with a caliper and correlated with mortality, days of mechanical ventilation, and length of hospital stay (LOS). RESULTS: There was a significant correlation (R = 0.84, p < 0.001) between TAPM of the right and the left hand. Severe malnourished patients showed TAPM of both the left (12.3 ± 5.5 mm) and right sides (12.9 ± 5.3 mm) significantly lower (p < 0.001) than either patients scored as nourished (right hand = 17.2 ± 5.4 mm and left hand = 15.8 ± 4.6 mm). Risk of death was approximately 8 times higher in patients with APACHEII score above 20 (OR: 8.6, 95% CI: 3.7-20.2; p < 0.001), and approximately 6 times higher in subjects with abnormal TAPM (OR: 6.3, 95% CI: 1.2-32.6; p = 0.02). However, TAPM did not correlate with length of stay and days of mechanical ventilation. CONCLUSION: TAPM is a valuable tool to predict mortality in critically ill patients.

Enteral or parenteral nutrition in traumatic brain injury: a prospective randomised trial.

INTRODUCTION: Few studies have evaluated the route of nutritional therapy in patients with head trauma. OBJECTIVE: We aimed at investigating whether early enteral (EN) or parenteral nutrition (TPN) may differ in protein/ calorie supply, serum glucose modifications, and acute phase response in patients with traumatic brain injury (TBI). METHODS: Twenty two patients with moderate TBI (Glasgow score between 9-12) were randomized to receive isocaloric and isonitrogeneous either EN (n=12) or TPN (n=10). The daily amount of calories and nitrogen (N) supplied, the nitrogen balance, and the daily serum level of glucose, C-reactive protein, and albumin were collected for 5 consecutive days. Clinical endpoints as length of stay and mortality were also compared. RESULTS: Mortality was 9.1% (two cases) with one case in each group. A progressive caloric deficit occurred in both groups (p=0.001) without difference between them. The mean serum glucose level in TNP patients (134.4, 95% CI=122.6 to 146.2 mg/dl) was significantly higher than in the EN group (102,4; 95% CI 91.6 to 113.2 mg/dL) (p<0.001). There was a trend (p=0.06) of 24 h urinary N loss to be greater in TPN group which received higher amounts of N than the NE group (p<0.05). However, nitrogen balance was similar in the two groups. There was no difference in either the clinical outcome variables or the acute phase response. CONCLUSION: Both routes were able to supply increasing provision of calories to brain injured patients. TPN provided significantly greater amount of nitrogen but losses were also greater. Nitrogen balance was similar with both types of therapy. Parenteral compared to enteral nutrition lead to greater hyperglycemia. There was no influence of the route in both the early inflammatory response and clinical outcome.

Oral glutamine in addition to parenteral nutrition improves mortality and the healing of high-output intestinal fistulas.

OBJECTIVE: Anastomotic leakage is one of the most important causes of morbidity and mortality in gastrointestinal surgery. We investigated the effect of oral glutamine on the healing of high-output intestinal fistula. SETTING: A tertiary Universitary Hospital of the University of Mato Grosso, Cuiaba, Brazil. PATIENTS AND METHODS: 28 patients (25 males and 3 females; median age = 45 [18-71] years old) admitted with high output post-operative small bowel fistulas (median volume in 24 h: 850 [600-2,200] mL) during a 4 years period were retrospectively studied. INTERVENTIONS: In the first two years 19 (67.9%) patients received only TPN as the initial nutritional support. In the last two years however, due to a change in the protocol for the nutritional support in cases of intestinal fistula 9 patients (32.1%) received oral glutamine (0.3 g/kg/day; 150 mL/day) in addition to TPN. Endpoints of the study were mortality, resolution of the fistula, and length of hospital stay (LOS). RESULTS: The overall mortality was 46.4% (13 patients). Fistula closure was observed in all other 15 patients (53.6%) that survived. In the subset of survived patients LOS was similar in those who received or not received glutamine. The multivariate regression analysis showed that resolution of the fistula was 13 times greater in patients that received oral glutamine (OR = 13.2 (95% CI = 1.1-160.5); p = 0.04) and 15 times greater in non-malnourished patients (OR = 15.4 [95% CI = 1.1-215.5]; p = 0.04). CONCLUSIONS: We conclude that oral glutamine accelerated the healing and diminished the mortality in this series of patients with post-operative high-output intestinal fistula receiving TPN.

Evolution of nutritional therapy prescription in critically ill patients.

AIM: The aim of this study was to investigate factors that may affect the evolution of the caloric prescription in critically ill patients. Local: Intensive care unit patients. PATIENTS: 60 patients (33 M and 27 F); median age = 49 (1593) y were followed prospectively. They were divided in three groups according to the diagnostic: (a) trauma (n=20); (b) surgical (n=22), and 3) medical treatment (n=18). Forty-and-one (68.3%) patients received enteral nutrition (EN), 17 (28.3%) parenteral nutrition (TPN), and 2 (3.4%) TNP and EN. Nutritional status was graded B or C by global subjective evaluation. METHODS: Endpoints of the study were the time to begin the nutritional support, success or failure of the caloric prescription, and the evolution of the planned caloric prescription. The caloric evolution was considered as success if the prescription for the patient attained: (a) 25% of the caloric requirements on the 1st day; (b) 50% until the 3rd day; (c) 75% until the 6th day; and (e) 100% until the 10th day of the beginning of the support. RESULTS: In 54 (90%) patients, the nutritional support has begun until 48 h after admission and in 73.3% (44 patients), until the first 24 hours. EN was most prescribed for both trauma and medical patients while NPT was most used for surgical patients (p < 0.01). Success in caloric prescription was obtained in 73.3% (44) of the patients. There was no statistical difference for the success on the evolution of the prescription related to sex, age, diagnostic group, albumin level, type of support, mortality, use of fiber or glutamine. Success was attained earlier in patients without (median = 3.8 [95% CI, 5.7-16.7] days) than with (11.2 [95% CI, 5.7-16.7] days; p < 0.01) mechanical ventilation. CONCLUSIONS: Early nutritional support and success on the evolution of the caloric prescription can be accomplished in most critically ill patients. Evolution of the caloric prescription was slower in mechanical ventilated patients.

Benefits of intraluminal injection of glutamine for intestinal mucosa during ischemia-reperfusion.

BACKGROUND: We investigated the effect of intraluminal glutamine on the intestinal mucosa in the presence of ischemia-reperfusion injury (IRI). METHODS: Six blind sacs were created in the small bowel (3 at the jejunum and 3 at the ileum) in 10 Wistar rats. The lateral sacs of both bowel regions were submitted to IRI (30/30 min), while the medial sacs were left free to receive blood supply. In the lateral sacs, a solution containing either saline plus 4% glutamine or pure saline was injected at the bowel lumen. No fluid was injected in the medial sacs. RESULTS: Both at the jejunum and at the ileum, the score of the mucosal injury was higher in saline-injected sacs than in either glutamine-injected or control sacs. There was a significantly greater number of neutrophils in the sacs treated with saline than in the other two groups of sacs. CONCLUSION: Glutamine protects the mucosa and diminishes the accumulation of neutrophils at the lamina propria of the small bowel in IRI.