Stress metabolism and nutritional support in acute renal failure.

International audienc

Légionelloses graves (évaluation du pronostic sur 28 cas observés en réanimation médicale et revue de la littérature)

Les données épidémiologiques sur des séries de réanimation sont rares. Cette étude rétrospective a été réalisée sur 28 patients (âge moyen : 53 ans), hospitalisés dans le service de réanimation médicale du C.H.R.U. de Grenoble entre 1988 et 2002 pour détresses respiratoires sévères et/ou chocs septiques. La mortalité globale fut faible (17,8 %) malgré la fréquence des défaillances multi-viscérales (68 %). Les éléments remarquables de l'étude sont : la forte prévalence du terrain dans l'échantillonnage (maladies sous-jacentes, éthylo-tabagisme, âge avancé, sexe masculin, immuno-suppression) conforte le rôle de ce dernier dans l'acquisition de la maladie. Les patients à risque cardio-vasculaire dégagent un profil évolutif plus défavorable ; l'apparition des premiers symptômes, tout comme les délais de prise en charge en établissement de soins puis en réanimation, sont plus courts dans les cas de légionellose qui aboutissent au décès : même si le terrain est essentiel, les légionelloses ont des expressions cliniques et des potentiels de gravité variables ; l'influence sur la mortalité de la rapidité de la prise en charge hospitalière ou de la mise en route d'une antibiothérapie adaptée, démontrée par la littérature, n'est pas évidente sur cette série ; le rein : un organe cible de la bactérie (78 % d'insuffisances rénales aiguës) ; l'anurie : un facteur net d'association avec le décès ; l'impact d'une éventuelle diminution de la mortalité grâce au dépistage rapide par l'antigénurie, même s'il accélère la mise en route d'un traitement adéquate, n'est pas mis en lumière ; la rareté des co-infections concomitantes au diagnostic de légionellose renforce le choix de n'utiliser qu'une antibiothérapie à spectre étroit. De nombreuses questions restent en suspens quant à l'efficacité des nouvelles molécules (versus érythromycine). D'autres mesures sont toutes aussi essentielles et tiennent de la prévention. La déclaration immédiate de tout cas de légionellose à l'autorité sanitaire, imposée par la loi, et l'envoi des prélèvements au Centre National de Référence pour une recherche rapide des souches bactériennes, font partie des réflexes à promouvoirGRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Controversy: Use of semi-elemental mixtures in enteral nutrition

Semi-elemental enteral nutrition mixtures are defined, by comparison with polymeric mixtures, by their content of small peptides and/or hydrolyzed protein (vs. intact protein), and a high proportion of medium-chain triglycerides (instead of long-chain triglycerides). The easier digestion is presumed to faVor intestinal absorption and improve the efficacy of enteral nutrition in clinical settings when protein hydrolysis is impaired: exocrine pancreatic insufficiency, acute pancreatitis, enteral nutrition administered into a jejunum, duodeno-pancreatectomy, interruption of biliary flow, short bowel syndrome. Even though a few small randomized trials suggest satisfactory tolerance of semi-elemental mixtures in acute pancreatitis, and improved nitrogen bioavailability in jejunal nutrition or in short bowel syndrome, hard evidence and controlled trials are scarce. The use of semi-elemental mixtures with low long-chain triglycerides to reduce lymph secretion is warranted in chylothorax or chylous ascites. There is, however, no strong evidence for an improved trophic or anti-inflammatory effect of semi-elemental, vs. polymeric mixtures in chronic inflammatory bowel disease. The higher osmolarity of semi-elemental mixtures exposes to a higher risk of poor gastrointestinal tolerance, and the nature of nitrogen supply, to a risk of impaired net protein accretion. In summary, although semi-elemental mixtures emerged over 30 years ago, there is no decisive proof of their superiority over polymeric mixtures, so the prescription of semi-elemental mixtures should probably be restricted to specific clinical settings such as chylous ascites, and in some cases of severe malabsorption, or as a second line treatment when polymeric mixtures fail. Yet such indications only rely on expert opinions, rather than strong evidence. (C) 2017 Association pour le developpement de la recherche en nutrition (ADREN)

Evolution of renal function in patients with severe intestinal failure on home parenteral nutrition

International audienceAbstract Background Kidney disease is a frequent but underestimated complication in patients suffering from intestinal failure (IF) treated by long-term home parenteral nutrition (HPN). The evolution in glomerular filtration rate (GFR) over time is poorly characterized. The current equations for estimating GFR have limited precision. No study has specifically investigated the reliability of recent creatinine-based estimated GFR (eGFR) equations in this population. The aim of this study was to evaluate the renal function decline under home parenteral nutrition (HPN) with a gold standard method and compare the performances of routinely used eGFR equations. Methods Forty patients with HPN and two or more GFR measurements were retrospectively studied. The renal function decline was calculated by the slope drawn between the successive measured GFRs (mGFRs). The performances of the Modification of Diet in Renal Disease, Chronic Kidney Disease Epidemiology Collaboration, full age spectrum and revised Lund–Malmö equations were compared with reference methods (inulin or iohexol clearance). Results The mean mGFR was 78 ± 28 mL/min/1.73 m2. The annual decline of mGFR was −1.9 mL/min/1.73 m2/year. No predisposing factor was identified to predict impairment in renal function. eGFR formulas grossly overestimated mGFR and had a low level of accuracy. Conclusions Patients with IF are at significant risk for impaired renal function. In this population, the tested eGFR equations were inaccurate. However, monitoring kidney function with mGFR remains important in these patients, as their GFR regularly declines and no specific risk factor has yet been identified

Nutrition entérale à domicile en site jéjunal [Home enteral nutrition by the jejunal route]

La nutrition en site jéjunal s’est encore développée, particulièrement lors de troubles de la déglutition, de reflux gastro-œsophagien et d’obstacle sur le tube digestif haut. L’accès au jéjunum n’est plus réservé à la chirurgie mais peut reposer aujourd’hui sur les techniques de pose de sonde et de stomie par voie endoscopique et radiologique. Ce cas clinique concernant un patient ayant fait un accident vasculaire cérébral permet de faire le point sur ces nouvelles techniques de jéjunostomie et gastrojéjunostomie. Elles se révèlent précieuses pour la nutrition à domicile car elles limitent le recours à une laparotomie ou laparoscopie, voire à une nutrition parentérale. [Jejunal nutrition has developed nowadays, especially for patients with swallowing disorders, severe gastro-oesophageal reflux disease or previous history of aspiration pneumonia, and obstruction of the upper GI tract. Access to the jejunum is no longer restricted to surgery thanks to the development of tube feeding insertions radiological and endoscopic techniques. This clinical case of a stroke patient underlines the clinical indications of these recent radiology or endoscopy-guided jejunostomies and gastrojejunostomies. They are suitable for home nutrition support as they could avoid surgical laparotomy or laparoscopy or even, parenteral nutrition.]]]> Internal Medicine; Nutrition and Dietetics; Endocrinology, Diabetes and Metabolism fre oai:serval.unil.ch:BIB_FB02A9DAD33D 2022-05-07T01:30:36Z <oai_dc:dc xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:xs="http://www.w3.org/2001/XMLSchema" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:oai_dc="http://www.openarchives.org/OAI/2.0/oai_dc/" xsi:schemaLocation="http://www.openarchives.org/OAI/2.0/oai_dc/ http://www.openarchives.org/OAI/2.0/oai_dc.xsd"> https://serval.unil.ch/notice/serval:BIB_FB02A9DAD33D Recommendations for the use of multimodal monitoring in the neurointensive care unit. info:doi:10.1097/MCC.0000000000000179 info:eu-repo/semantics/altIdentifier/doi/10.1097/MCC.0000000000000179 info:eu-repo/semantics/altIdentifier/pmid/25689123 Citerio, G. Oddo, M. Taccone, F.S. info:eu-repo/semantics/review article 2015 Current Opinion in Critical Care, vol. 21, no. 2, pp. 113-119 info:eu-repo/semantics/altIdentifier/eissn/1531-7072 urn:issn:1070-5295 <![CDATA[PURPOSE OF REVIEW: Multimodal monitoring (MMM) is routinely applied in neurointensive care. Unfortunately, there is no robust evidence on which MMM-derived physiologic variables are the most clinically relevant, how and when they should be monitored, and whether MMM impacts outcome. The complexity is even higher because once the data are continuously collected, interpretation and integration of these complex physiologic events into targeted individualized care is still embryonic. RECENT FINDINGS: Recent clinical investigation mainly focused on intracranial pressure, perfusion of the brain, and oxygen availability along with electrophysiology. Moreover, a series of articles reviewing the available evidence on all the MMM tools, giving practical recommendations for bedside MMM, has been published, along with other consensus documents on the role of neuromonitoring and electroencephalography in this setting. SUMMARY: MMM allows comprehensive exploration of the complex pathophysiology of acute brain damage and, depending on the different configuration of the pathological condition we are treating, the application of targeted individualized care. Unfortunately, we still lack robust evidence on how to better integrate MMM-derived information at the bedside to improve patient management. Advanced informatics is promising and may provide us a supportive tool to interpret physiologic events and guide pathophysiological-based therapeutic decisions

Recommandations formalisées d'experts. Contrôle de la glycémie en réanimation et en anesthésie: une réactualisation nécessaire.

0GuidelineJournal ArticleReviewSociété française d'anesthésie et de réanimation (SFAR); Société de réanimation de langue française (SRLF)info:eu-repo/semantics/publishe

Glucose appearance in the peripheral circulation and liver glucose output in men after a large 13C starch meal.

International audienceBACKGROUND: Glucose absorption from starchy food has only been described with small amounts ingested ( approximately 20-75 g). OBJECTIVE: Our aim was to describe total plasma (Ra) and exogenous glucose (Ra(exo)) appearance, glucose release from the liver (HGP), and the metabolic response after ingestion of 5 g polished or parboiled rice/kg body mass. DESIGN: Gas exchange and urea excretion were monitored in 8 healthy subjects before (3.5 h) and after (8 h) ingestion of rice intrinsically labeled with (13)C; [6,6-(2)H(2)]glucose was infused for the measurement of Ra, Ra(exo), and HGP. RESULTS: Changes in plasma glucose, insulin, lactate, and free fatty acids and the increase in Ra(exo) and Ra ( approximately 200%) and the decrease in HGP ( approximately 90%) were not significantly different (P > 0.05) after ingestion of either rice. Glucose oxidation was not significantly different (111.6 +/- 8.2 compared with 89.0 +/- 11.3 g; P = 0.13), but fat oxidation was significantly lower (9.9 +/- 1.7 compared with 21.3 +/- 4.0 g; P 0.05). CONCLUSION: Although the starch in parboiled rice is less susceptible to digestion in vitro, exogenous glucose availability was not significantly different after ingestion of large amounts of polished or parboiled rice. Glucose absorption remains incomplete 8 h after ingestion of both types of rice

Glucose appearance in the peripheral circulation and liver glucose output in men after a large 13C starch meal.

International audienceBACKGROUND: Glucose absorption from starchy food has only been described with small amounts ingested ( approximately 20-75 g). OBJECTIVE: Our aim was to describe total plasma (Ra) and exogenous glucose (Ra(exo)) appearance, glucose release from the liver (HGP), and the metabolic response after ingestion of 5 g polished or parboiled rice/kg body mass. DESIGN: Gas exchange and urea excretion were monitored in 8 healthy subjects before (3.5 h) and after (8 h) ingestion of rice intrinsically labeled with (13)C; [6,6-(2)H(2)]glucose was infused for the measurement of Ra, Ra(exo), and HGP. RESULTS: Changes in plasma glucose, insulin, lactate, and free fatty acids and the increase in Ra(exo) and Ra ( approximately 200%) and the decrease in HGP ( approximately 90%) were not significantly different (P > 0.05) after ingestion of either rice. Glucose oxidation was not significantly different (111.6 +/- 8.2 compared with 89.0 +/- 11.3 g; P = 0.13), but fat oxidation was significantly lower (9.9 +/- 1.7 compared with 21.3 +/- 4.0 g; P 0.05). CONCLUSION: Although the starch in parboiled rice is less susceptible to digestion in vitro, exogenous glucose availability was not significantly different after ingestion of large amounts of polished or parboiled rice. Glucose absorption remains incomplete 8 h after ingestion of both types of rice

Référentiel de pratiques professionnelles: soins et surveillance des accès veineux centraux de l'adulte pour la nutrition parentérale [Formative assessment in clinical nutrition: Care management of parenteral nutrition central venous access]

Les voies veineuses centrales (VVC) sont essentielles pour l'administration de la nutrition parentérale. Le risque de complications est dépendant de la qualité des soins apportés à la VVC qui influence de ce fait la qualité de vie des patients et le coût des soins. Beaucoup de complications des VVC, infectieuses ou non, peuvent être prévenues par l'existence de protocoles de soins appropriés et standardisés. L'information sur les soins des VVC et les éventuelles complications est essentielle pour le dépistage et le traitement précoce de ces complications ; elle doit faire l'objet de protocoles partagés entre les patients et les soignants. Cet article décrit une évaluation des pratiques professionnelles sous la forme d'un audit clinique destiné à améliorer la qualité de soins des patients en nutrition parentérale porteurs de VVC. Central venous access devices (CVAD) are essential for the administration of parenteral nutrition. The quality of the care of CVAD influences the risk of complications and so the quality of life of the patients and the costs of care. Numerous infectious or non-infectious complications of CVAD can be prevented by appropriate, standardized protocols of care. Information about the care of CVAD and complications is essential for the early recognition and treatment of complications and should be shared between patients and caregivers. This article describes an audit for CAVD care that can be used to improve quality of care in a professional practice evaluation program

Hyperphagia in short bowel patients: Fat-free mass is a strong predictor

International audienceObjectives Some patients with short bowel syndrome (SBS) develop hyperphagic behavior. Such an increase in food intake stimulates intestinal adaptation and limits dependence on parenteral nutrition (PN). The aim of this study was to determine the factors modulating food consumption in patients with SBS. Methods The associations between oral energy intake (OEI) and anthropometric, metabolic, nutritional, and intestinal absorption–related characteristics were determined in a monocentric cohort of patients with SBS on PN with a stable nutritional status. Body composition was assessed by dual x-ray absorptiometry. Data were retrospectively collected from clinical records. Results After screening, 38 adult patients with a SBS on PN were included in this study. OEI ranged from 577 to 4054kcal/d. OEI correlated positively with weight, fat-free mass, handgrip strength, and resting energy expenditure (REE) and negatively with free triiodothyronine and C-reactive protein using Spearman correlation. Fat-free mass and thyroid-stimulating hormone remained positively correlated with OEI independently of all other parameters in a multilinear regression model. Conclusions Fat-free mass is a strong predictor of OEI in patients with SBS on PN and without debilitating gastrointestinal symptoms. Increasing fat-free mass could be a way to stimulate OEI in these patients. Further studies are needed to assess this assumption