Nutritional care in hospitalized patients with chronic liver disease

AIM: To evaluate the practice of nutritional assessment and management of hospitalised patients with cirrhosis and the impact of malnutrition on their clinical outcome. METHODS: This was a retrospective cohort study on patients with liver cirrhosis consecutively admitted to the Department of Gastroenterology and Hepatology at the Royal Adelaide Hospital over 24 mo. Details were gathered related to the patients’ demographics, disease severity, nutritional status and assessment, biochemistry and clinical outcomes. Nutritional status was assessed by a dietician and determined by subjective global assessment. Estimated energy and protein requirements were calculated by Simple Ratio Method. Intake was estimated from dietary history and/or food charts, and represented as a percentage of estimated daily requirements. Median duration of follow up was 14.9 (0-41.4) mo. RESULTS: Of the 231 cirrhotic patients (167 male, age: 56.3 ± 0.9 years, 9% Child-Pugh A, 42% Child-Pugh B and 49% Child-Pugh C), 131 (57%) had formal nutritional assessment during their admission and 74 (56%) were judged to have malnutrition. In-hospital caloric (15.6 ± 1.2 kcal/kg vs 23.7 ± 2.3 kcal/kg, P = 0.0003) and protein intake (0.65 ± 0.06 g/kg vs 1.01 ± 0.07 g/kg, P = 0.0003) was significantly reduced in patients with malnutrition. Of the malnourished cohort, 12 (16%) received enteral nutrition during hospitalisation and only 6 (8%) received ongoing dietetic review and assessment following discharge from hospital. The overall mortality was 51%, and was higher in patients with malnutrition compared to those without (HR = 5.29, 95%CI: 2.31-12.1; P < 0.001). CONCLUSION: Malnutrition is common in hospitalised patients with cirrhosis and is associated with higher mortality. Formal nutritional assessment, however, is inadequate. This highlights the need for meticulous nutritional evaluation and management in these patients.Dep K Huynh, Shane P Selvanderan, Hugh AJ Harley, Richard H Holloway, Nam Q Nguye

Pantoprazole or placebo for stress ulcer prophylaxis (POP-UP): randomized double-blind exploratory study

Objectives: Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Our objective was to evaluate benefit or harm associated with pantoprazole administration. Design: Prospective randomized double-blind parallel-group study. Setting: University-affiliated mixed medical-surgical ICU. Patients: Mechanically ventilated critically ill patients suitable for enteral nutrition. Interventions: We randomly assigned patients to receive either daily IV placebo or pantoprazole. Measurements and Main Results: Major outcomes were clinically significant gastrointestinal bleeding, infective ventilatorassociated complication or pneumonia, and Clostridium difficile infection; minor outcomes included overt bleeding, hemoglobin concentration profiles, and mortality. None of the 214 patients randomized had an episode of clinically significant gastrointestinal bleeding, three patients met the criteria for either an infective Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001819 *See also p. 1939. 1Discipline of Acute Care Medicine, the University of Adelaide, Adelaide, SA, Australia. 2Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia. 3National Health and Medical Research Council of Australia Centre for Research Excellence in Nutritional Physiology and Outcomes, Adelaide, SA, Australia. 4Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia. 5Discipline of Medicine, the University of Adelaide, Adelaide, SA, Australia. This work was performed at the Intensive Care Unit, Royal Adelaide Hospital. Supported, in part, by a project grant from the Royal Adelaide Hospital Research Foundation. Dr. Selvanderan contributed to study concept and design, acquisition, analysis, and interpretation of data and drafting of the article. Mr. Summers contributed to the acquisition, analysis and interpretation of data and critical revision of the manuscript for important intellectual content. Dr. Finnis contributed to study concept and design, acquisition, analysis and interpretation of data, statistical analysis, and critical revision of the article for important intellectual content. Dr. Plummer contributed to study concept and design, acquisition, analysis, and interpretation of data, and critical revision of the article and obtained funding for important intellectual content. Dr. Ali Abdelhamid contributed to acquisition, analysis, and interpretation of data and critical revision of the article for important intellectual content. Dr. Anderson contributed to acquisition, analysis, and interpretation of data and critical revision of the article for important intellectual content. Dr. Chapman contributed to acquisition, analysis, and interpretation of data and critical revision of the article for important intellectual content. Dr. Rayner contributed to acquisition, analysis, and interpretation of data and critical revision of the article for important intellectual content. Dr. Deane contributed to study concept and design, acquisition, analysis, and interpretation of data, drafting of the article and study supervision and obtained funding. All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study* Shane P. Selvanderan, BMEdSci (Hon), MBBS1; Matthew J. Summers, BSc, MDiet2; Mark E. Finnis, MBBS, MBiostat1,2; Mark P. Plummer, MBBS, PhD1,2; Yasmine Ali Abdelhamid, MBBS2; Michael B. Anderson, MBChB2; Marianne J. Chapman, MBBS, PhD1,2,3; Christopher K. Rayner, MBBS, PhD3,4,5; Adam M. Deane, MBBS, PhD1,2,3 Trial Registration: Australian New Zealand Clinical Trials Registry (http:// www.anzctr.org.au, trial ID: ACTRN12613000807752). Dr. Selvanderan received funding from the Royal Adelaide Hospital Research Foundation (honours scholarship). His institution received funding from the Royal Adelaide Hospital Research Foundation (project grant). Mr. Summers’ institution received funding from the Royal Adelaide Hospital Research Foundation (project grant). Dr. Ali Abdelhamid received funding (the project was funded by a project grant from the Royal Adelaide Hospital Research Foundation). Dr. Rayner disclosed off-label product use (pantoprazole for prevention of stress ulceration). His institution received funding from the Royal Adelaide Hospital Research Foundation (project grant), AstraZeneca, Merck, and Novartis. Dr. Deane was supported by an early career fellowship from the National Health and Medical Research Council. His institution received funding from the Royal Adelaide Hospital Research Foundation (project grant). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Clinical Investigations Critical Care Medicine www.ccmjournal.org 1843 ventilator-associated complication or pneumonia (placebo: 1 vs pantoprazole: 2), and one patient was diagnosed with Clostridium difficile infection (0 vs 1). Administration of pantoprazole was not associated with any difference in rates of overt bleeding (6 vs 3; p = 0.50) or daily hemoglobin concentrations when adjusted for transfusion rates of packed red cells (p = 0.66). Mortality was similar between groups (log-rank p = 0.33: adjusted hazard ratio for pantoprazole: 1.68 [95% CI, 0.97–2.90]; p = 0.06). Conclusions: We found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition. The practice of routine administration of acid-suppressive drugs to critically ill patients for stress ulcer prophylaxis warrants further evaluation. (Crit Care Med 2016; 44:1842–1850)Shane P. Selvanderan, Matthew J. Summers, Mark E. Finnis, Mark P. Plummer, Yasmine Ali Abdelhamid, Michael B. Anderson, Marianne J. Chapman, Christopher K. Rayner, Adam M. Dean

Occult upper gastrointestinal mucosal abnormalities in critically ill patients

Background: The objectives of this study were to estimate the frequency of occult upper gastrointestinal abnormalities, presence of gastric acid as a contributing factor, and associations with clinical outcomes. Methods: Data were extracted for study participants at a single centre who had an endoscopy performed purely for research purposes and in whom treating physicians were not suspecting gastrointestinal bleeding. Endoscopic data were independently adjudicated by two gastroenterologists who rated the likelihood that observed pathological abnormalities were related to gastric acid secretion using a 3-point ordinal scale (unlikely, possible or probable). Results: Endoscopy reports were extracted for 74 patients [age 52 (37, 65) years] undergoing endoscopy on day 5 [3, 9] of ICU admission. Abnormalities were found in 25 (34%) subjects: gastritis/erosions in 10 (14%), nasogastric tube trauma in 8 (11%), oesophagitis in 4 (5%) and non-bleeding duodenal ulceration in 3 (4%). The contribution of acid secretion to observed pathology was rated 'probable' in six subjects (rater #1) and five subjects (rater #2). Prior to endoscopy, 39 (53%) patients were receiving acid-suppressive therapy. The use of acid-suppressive therapy was not associated with the presence of an endoscopic abnormality (present 15/25 (60%) vs. absent 24/49 (49%); P = 0.46). Haemoglobin concentrations, packed red cells transfused and mortality were not associated with mucosal abnormalities (P = 0.83, P > 0.9 and P > 0.9 respectively). Conclusions: Occult mucosal abnormalities were observed in one-third of subjects. The presence of mucosal abnormalities appeared to be independent of prior acid-suppressive therapy and was not associated with reduced haemoglobin concentrations, increased transfusion requirements, or mortality.C. Ovenden, M.P. Plummer, S. Selvanderan, T.A. Donaldson, N.Q. Nguyen, L.M. Weinel, M.E. Finnis, M.J. Summers, Y. Ali Abdelhamid, M.J. Chapman, C.K. Rayner and A.M. Dean