Early enteral nutrition compared to outcome in critically ill trauma patients at a level one trauma centre

Objectives: The benefit of an early enteral nutrition start in critical ill patients is widely accepted. However, limited published data focus on trauma patients. This study aimed to investigate the effect of early enteral nutrition initiation on length of stay and mortality in an intensive care unit (ICU), as well as explore if enteral nutrition initiation could serve as a prognostic marker in trauma patients.Design: This was a retrospective audit of a prospective ethics-approved database (University of KwaZulu-Natal Biomedical Research Ethics Committee No BE207-09) which compared enteral nutrition to outcome.Setting: The setting was a level 1 trauma ICU in Durban, South Africa.Subjects: The subjects were critically ill trauma patients.Outcome measures: Demographic data, enteral nutrition timing, feed tolerance, and the outcome of early versus late initiation of enteral feeding were the outcome measures.Results: Nine hundred and fifty-two patients were included. Eight hundred and ninety-eight received enteral nutrition and were divided into three subgroups (tertiles T1-T3) according to their Injury Severity Score (ISS). The statistical analysis demonstrated that an early enteral nutrition start had a significant positive effect on both length of stay (13.7 vs. 16.4 days, p-value 0.00315) and mortality (9.5 % vs. 20.7 % p-value 0.0062). A multiple logistic regression model was developed, using multiple variables, to test the factors that affected the outcome. There was a significant effect on length of stay with an early enteral nutrition start in patients with a low to medium ISS (T1), and a highly significant effect on mortality in patients with a low to medium, and high, ISS (T1 and T2). Early initiation of enteral nutrition is strongly favoured in regression analyses.Conclusion: Patients in the trauma ICU benefit from an early enteral nutrition. The model used featuring the three independent variables, i.e. the day on which enteral nutrition is commenced, age and ISS, may serve as a prognostic marker with regard to length of stay and mortality in the ICU.Keywords: enteral nutrition, early initiation, outcome predictio

Complications relating to enteral and parenteral nutrition in trauma patients: a retrospective study at a level one trauma centre in South Africa

Objectives: The aim of the study was to compare the incidence of complications in patients receiving enteral and parenteral nutrition (PN), and review how the early initiation of enteral feeding and early achievement of caloric goal would affect the incidence of complications.Design: The design was a retrospective audit of an ethics-approved prospective trauma registry and electronic medical record.Setting: The setting was a level one trauma centre intensive care unit.Subjects: One thousand and two consecutively treated patients were selected from 1 096 in the database.Outcome measures: Demographic data, nutrition, route of administration, time of initiation and complications in the form of sepsis, pneumonia and feed intolerance, were determined.Results: Patients receiving total PN (TPN) during their length of stay had a hazard ratio of 9.11 for the development of sepsis, compared to patients who were solely fed via the enteral route (p-value <0.001). The patients who reached their nutritional goal late showed a hazard ratio of 2.67 for the development of sepsis, compared to patients who reached the goal early (p-value < 0.001). Patients with late initiation of feeding also had a greater risk of developing sepsis, with a hazard ratio of 2.41, compared to patients with early initiation (p-value < 0.001). Patients achieving the nutritional goal late had a 17.9% increased risk of developing pneumonia (p-value < 0.001).Conclusion: This study confirms previous findings that the use of TPN is a strong predictor of the development of sepsis, compared to enteral nutrition. Causality linkage should be made with caution owing to the study design.Keywords: complications, critical illness, nutrition, trauma, outcom

Randomised trial of glutamine and selenium supplemented parenteral nutrition for critically ill patients

Background: Mortality rates in the Intensive Care Unit and subsequent hospital mortality rates in the UK remain high. Infections in Intensive Care are associated with a 2–3 times increased risk of death. It is thought that under conditions of severe metabolic stress glutamine becomes "conditionally essential". Selenium is an essential trace element that has antioxidant and anti-inflammatory properties. Approximately 23% of patients in Intensive Care require parenteral nutrition and glutamine and selenium are either absent or present in low amounts. Both glutamine and selenium have the potential to influence the immune system through independent biochemical pathways. Systematic reviews suggest that supplementing parenteral nutrition in critical illness with glutamine or selenium may reduce infections and mortality. Pilot data has shown that more than 50% of participants developed infections, typically resistant organisms. We are powered to show definitively whether supplementation of PN with either glutamine or selenium is effective at reducing new infections in critically ill patients. Methods/design: 2 × 2 factorial, pragmatic, multicentre, double-blind, randomised controlled trial. The trial has an enrolment target of 500 patients. Inclusion criteria include: expected to be in critical care for at least 48 hours, aged 16 years or over, patients who require parenteral nutrition and are expected to have at least half their daily nutritional requirements given by that route. Allocation is to one of four iso-caloric, iso-nitrogenous groups: glutamine, selenium, both glutamine & selenium or no additional glutamine or selenium. Trial supplementation is given for up to seven days on the Intensive Care Unit and subsequent wards if practicable. The primary outcomes are episodes of infection in the 14 days after starting trial nutrition and mortality. Secondary outcomes include antibiotic usage, length of hospital stay, quality of life and cost-effectiveness. Discussion: To date more than 285 patients have been recruited to the trial from 10 sites in Scotland. Recruitment is due to finish in August 2008 with a further six months follow up. We expect to report the results of the trial in summer 2009. Trial registration: This trial is registered with the International Standard Randomised Controlled Trial Number system. ISRCTN87144826Not peer reviewedPublisher PD

The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication

Glutamine supplementation

Intravenous glutamine supplementation is standard care when parenteral nutrition is given for critical illness. There are data of a reduced mortality when glutamine supplementation is given. In addition, standard commercial products for parenteral nutrition do not contain any glutamine due to glutamine instability in aqueous solutions. For the majority of critical ill patients who are fed enterally, the available evidence is insufficient to recommend glutamine supplementation. Standard formulation of enteral nutrition contains some glutamine: 2-4 g/L. However, this dose is insufficient to normalize glutamine plasma concentration

Mechanisms of Endothelial Dysfunction in Resistance Arteries from Patients with End-Stage Renal Disease

The study focuses on the mechanisms of endothelial dysfunction in the uremic milieu. Subcutaneous resistance arteries from 35 end-stage renal disease (ESRD) patients and 28 matched controls were studied ex-vivo. Basal and receptor-dependent effects of endothelium-derived factors, expression of endothelial NO synthase (eNOS), prerequisites for myoendothelial gap junctions (MEGJ), and associations between endothelium-dependent responses and plasma levels of endothelial dysfunction markers were assessed. The contribution of endothelium-derived hyperpolarizing factor (EDHF) to endothelium-dependent relaxation was impaired in uremic arteries after stimulation with bradykinin, but not acetylcholine, reflecting the agonist-specific differences. Diminished vasodilator influences of the endothelium on basal tone and enhanced plasma levels of asymmetrical dimethyl L-arginine (ADMA) suggest impairment in NO-mediated regulation of uremic arteries. eNOS expression and contribution of MEGJs to EDHF type responses were unaltered. Plasma levels of ADMA were negatively associated with endothelium-dependent responses in uremic arteries. Preserved responses of smooth muscle to pinacidil and NO-donor indicate alterations within the endothelium and tolerance of vasodilator mechanisms to the uremic retention products at the level of smooth muscle. We conclude that both EDHF and NO pathways that control resistance artery tone are impaired in the uremic milieu. For the first time, we validate the alterations in EDHF type responses linked to kinin receptors in ESRD patients. The association between plasma ADMA concentrations and endothelial function in uremic resistance vasculature may have diagnostic and future therapeutic implications

ISSN exercise & sport nutrition review: research & recommendations

Sports nutrition is a constantly evolving field with hundreds of research papers published annually. For this reason, keeping up to date with the literature is often difficult. This paper is a five year update of the sports nutrition review article published as the lead paper to launch the JISSN in 2004 and presents a well-referenced overview of the current state of the science related to how to optimize training and athletic performance through nutrition. More specifically, this paper provides an overview of: 1.) The definitional category of ergogenic aids and dietary supplements; 2.) How dietary supplements are legally regulated; 3.) How to evaluate the scientific merit of nutritional supplements; 4.) General nutritional strategies to optimize performance and enhance recovery; and, 5.) An overview of our current understanding of the ergogenic value of nutrition and dietary supplementation in regards to weight gain, weight loss, and performance enhancement. Our hope is that ISSN members and individuals interested in sports nutrition find this review useful in their daily practice and consultation with their clients