Pharmaconutrition with selenium in critically ill patients: what do we know?

Selenium is a component of selenoproteins with antioxidant, anti-inflammatory, and immunomodulatory properties. Systemic inflammatory response syndrome (SIRS), multiorgan dysfunction (MOD), and multiorgan failure (MOF) are associated with an early reduction in plasma selenium and glutathione peroxidase activity (GPx), and both parameters correlate inversely with the severity of illness and outcomes. Several randomized clinical trials (RCTs) evaluated selenium therapy as monotherapy or in antioxidant cocktails in intensive care unit (ICU) patient populations, and more recently several meta-analyses suggested benefits with selenium therapy in the most seriously ill patients. However, the largest RCT on pharmaconutrition with glutamine and antioxidants, the REducing Deaths due to Oxidative Stress (REDOXS) Study, was unable to find any improvement in clinical outcomes with antioxidants provided by the enteral and parenteral route and suggested harm in patients with renal dysfunction. Subsequently, the MetaPlus study demonstrated increased mortality in medical patients when provided extra glutamine and selenium enterally. The treatment effect of selenium may be dependent on the dose, the route of administration, and whether administered with other nutrients and the patient population studied. Currently, there are few small studies evaluating the pharmacokinetic profile of intravenous (IV) selenium in SIRS, and therefore more data are necessary, particularly in patients with MOD, including those with renal dysfunction. According to current knowledge, high-dose pentahydrate sodium selenite could be given as an IV bolus injection (1000-2000 µg), which causes transient pro-oxidant, cytotoxic, and anti-inflammatory effects, and then followed by a continuous infusion of 1000-1600 µg/d for up to 10-14 days. Nonetheless, the optimum dose and efficacy still remain controversial and need to be definitively established.

Tempo de jejum perioperatório versus tempo de permanência hospitalar e complicações pós operatórias em pacientes submetidos a cirurgias do trato gastrointestinal e de parede abdominal / Fasting time perioperative versus time hospital permanence and complications after surgical patients submitted to surgery of the gastrointestinal tract and abdominal wall

Introdução: Pacientes cirúrgicos são expostos a jejum perioperatório prolongado podendo agravar a resposta metabólica ao trauma. Objetivo: identificar o tempo de jejum pré e pósoperatório e associar à incidência de complicações pós-operatórias e tempo de internamento em pacientes submetidos a cirurgias do trato gastrointestinal e de parede abdominal. Métodos: Trata-se de um estudo prospectivo observacional realizado com pacientes cirúrgicos internados no período de abril a outubro de 2013. Considerou-se o tempo de jejum pré-operatório a diferença (em horas) da última refeição realizada até o início do procedimento cirúrgico. O jejum pós-operatório foi contabilizado a partir da diferença (em horas) entre o final do procedimento cirúrgico e o reinício da dieta. As operações foram divididas em porte I (operações envolvendo parede abdominal e laparotomias sem abertura de alças e/ou manipulação de vias biliares) e porte II (operações envolvendo laparotomias com abertura de alças e/ou manipulação de vias biliares). As complicações pós-operatórias avaliadas por um período de até 30 dias após o procedimento cirúrgico. O tempo (em dias) de interna- ção pós-operatória foi calculado pela diferença entre a data da alta e a data da cirurgia. Para análise dos resultados utilizou-se o programa estatístico Sigma Stat 13.0, empregando-se o nível de confiança de 95%. Resultados: Não houve diferença nas medianas do tempo de jejum pré-operatório entre as cirurgias do porte I e II. Os pacientes que realizaram cirurgia do porte II permaneceram mais tempo em jejum pós-operatório ( p<0,001) e por mais tempo internados (p<0,001). Houve maior percentual de complicações nas cirurgias do porte II ( p= 0,001). Discussão: A nutrição tanto no pré como no pósoperatório tem papel relevante, diminuindo a resposta orgânica ao estresse e interferindo de maneira significativa na evolução dos pacientes. Conclusão: O tempo de jejum pré-operatório foi superior ao preconizado pelos protocolos multimodais de abreviação do jejum, independente do porte cirúrgico. O tempo de jejum perioperatório alargado pode favorecer ao aumento do tempo de permanência hospitalar (AU)

Introduction: Surgical patients are exposed to prolonged perioperative fasting can aggravate the metabolic response to trauma. Objective: To identify the pre fasting period and after surgery and associate the incidence of postoperative complications and length of hospital stay in patients undergoing surgery of the gastrointestinal tract and abdominal wall. Methods: This is a prospective observational study of hospitalized surgical patients from April to October 2013. It was considered the preoperative fasting time difference (in hours) of the last meal accomplished at the beginning of the surgical procedure. Postoperative fasting was recorded from the difference (in hours) between the end of the surgical procedure and the diet restart. Operations were divided into size I (operations involving abdominal wall and laparotomy without opening handles and/or manipulation of the bile ducts) and size II (operations involving laparotomy with open handles and/or manipulation of the bile ducts). Postoperative complications assessed for a period of 30 days after surgery. The time (in days) of postoperative hospital stay was calculated as the difference between the date of discharge and the date of surgery. For data analysis we used the statistical software Sigma Stat 13.0, using the confidence level of 95%. Results: There was no difference in median preoperative fasting time between the size of the surgeries I and II. Patients who underwent surgery sized II stayed longer in postoperative fasting (p< 0.001) and in hospital longer (p<0.001). There was a higher percentage of complications in the size surgeries II (p = 0.001). Discussion: Nutrition both pre and post-operative has an important role, reducing organic response to stress and interfering significantly to patient outcomes. Conclusion: Preoperative fasting time was higher than the one from multimodal protocols of fasting abbreviation, regardless of surgical size. The extended perioperative fasting time may favor the increased length of hospital stay (AU)

Fish oil supplementation in the parenteral nutrition of critically ill medical patients: a randomised controlled trial.

OBJECTIVE: To test whether supplementation of parenteral nutrition with fish oil - aimed at increasing the n-3:n-6 ratio of polyunsaturated fatty acids (PUFA) to 1:2 - affects systemic inflammation and clinical outcome compared to standard parenteral nutrition with an n-3/n-6 ratio of 1:7 in medical intensive care unit (ICU) patients. DESIGN: Single-centre, placebo-controlled, double-blind, randomised clinical trial. SETTING: Twelve-bed medical ICU of a university hospital. PATIENTS: A total of 166 consecutive patients anticipated to need parenteral nutrition for more than 6 days. Patients were stratified for the presence of systemic inflammatory response syndrome (SIRS) at baseline (115 SIRS, 51 non-SIRS). INTERVENTION: Patients were randomly assigned to receive either a 1:1-mixture of medium-chain triglycerides (MCT) and long-chain triglycerides (LCT) with an n-3/n-6 PUFA ratio of 1:7, or the same MCT/LCT emulsion supplemented with fish oil (resulting in an n-3/n-6 ratio of 1:2). MEASUREMENTS AND RESULTS: Primary endpoints were changes in interleukin 6 (IL-6) and monocyte HLA-DR expression relative to baseline. Secondary endpoints were incidence of nosocomial infections, duration of mechanical ventilation, length of ICU stay, and 28-day mortality. Bleeding complications were recorded as a possible side effect of fish oil. Between standard and intervention groups, overall as well as stratified for SIRS or non-SIRS, no significant difference was detected in any of the endpoints or frequency and severity of bleeding events. CONCLUSIONS: In unselected critically ill medical patients, fish oil supplementation that increased the n-3/n-6 PUFA ratio to 1:2 did not affect inflammation or clinical outcome, compared to parenteral lipid nutrition with an MCT/LCT emulsion.

Review article: bacterial translocation in the critically ill--evidence and methods of prevention.

BACKGROUND: Delayed sepsis, systemic inflammatory response syndrome (SIRS) and multiorgan failure remain major causes of morbidity and mortality on intensive care units. One factor thought to be important in the aetiology of SIRS is failure of the intestinal barrier resulting in bacterial translocation and subsequent sepsis. AIM: This review summarizes the current knowledge about bacterial translocation and methods to prevent it. METHODS: Relevant studies during 1966-2006 were identified from a literature search. Factors, which detrimentally affect intestinal barrier function, are discussed, as are methods that may attenuate bacterial translocation in the critically ill patient. RESULTS: Methodological problems in confirming bacterial translocation have restricted investigations to patients undergoing laparotomy. There are only limited data available relating to specific interventions that might preserve intestinal barrier function or limit bacterial translocation in the intensive care setting. These can be categorized broadly into pre-epithelial, epithelial and post-epithelial interventions. CONCLUSIONS: A better understanding of factors that influence translocation could result in the implementation of interventions which contribute to improved patient outcomes. Glutamine supplementation, targeted nutritional intervention, maintaining splanchnic flow, the judicious use of antibiotics and directed selective gut decontamination regimens hold some promise of limiting bacterial translocation. Further research is required.

[COPD, a systemic disease--nutritional approaches]. / COPD, eine Systemerkrankung-ernährungstherapeutische Ansätze.

BACKGROUND: Within the last few years our knowledge concerning the pathogenesis of chronic obstructive pulmonary disease (COPD) has grown. We now know that COPD is not simply a lung disease but a type of systemic disease. The systemic inflammation which can be found in COPD and the oxidant burden lead to systemic changes in muscles, endocrinium, bones, and blood vessels. Patients with COPD are often undernourished and have a low muscle mass even if the body mass is normal. MUSCLE AND WEIGHT LOSS: Loss of muscle mass, caused by different mechanisms, influences the muscle endurance of COPD patients. Weight loss as well as loss of muscle mass are negatively correlated with morbidity and mortality of these patients. NUTRITIONAL SUPPORT AND EXERCISE: Nutritional support like dietary advice, including supplements especially in combination with exercise, which could improve the quality of life of these patients, are approaches which are not sufficiently considered in the treatment of COPD.

Characterization of nonresponse to high caloric oral nutritional therapy in depleted patients with chronic obstructive pulmonary disease.

Nutritional support can increase body weight and physiologic function in COPD, but there are some patients who do not respond to nutritional therapy. The aim of this prospective study was to describe the nonresponse to 8 wk of oral nutritional supplementation therapy (500 to 750 kcal/d extra), implemented in an inpatient pulmonary rehabilitation program, with respect to lung function, body composition, energy balance, and systemic inflammatory profile in 24 (16 male) depleted patients with COPD. On the basis of the weight change after 8 wk, patients were divided into three groups (Group 1: weight gain < 2% of baseline body weight, n = 5; Group 2: weight gain 2 to 5%, n = 9; Group 3: weight gain >/= 5%, n = 10). Although no differences were seen in lung function and body composition, Group 1 was characterized by older age, a lower baseline dietary intake/resting energy expenditure (REE) ratio, and a greater number of users of continuous supplemental oxygen when compared with Group 3. In addition, Group 1 exhibited higher baseline concentrations of fasting glucose and LPS-binding protein than did Groups 2 and 3. The concentrations of the soluble TNF- receptors 55 and 75 were elevated in Groups 1 and 2 when compared with Group 3. Furthermore, a significant, inverse correlation coefficient between baseline dietary intake and soluble intercellular adhesion molecule was revealed (r = -0.50, p = 0.016). On linear regression analysis, age, baseline intake/REE ratio, sTNF-receptor 55, and extracellular/intracellular water (ECW/ICW) ratio were selected as independent, significant parameters contributing to a total explained variation of 78% in weight change after nutritional therapy. In conclusion, nonresponse to nutritional therapy in COPD is associated with ageing, relative anorexia, and an elevated systemic inflammatory response. Further research is needed to investigate whether these factors contribute to eventual disturbances in intermediary metabolism as reflected by the increased glucose concentration and ECW/ICW ratio.