Abstract
The critically ill, stressed, sometimes undernourished may develop an intestinal dysfunction which leads to multiple organ failure. Early enteral nutrition (EN) is usually recommended but may fail to provide an adequate amount of substrate. Parenteral nutrition (PN) is used in case of failure or contraindications of EN. However, the role of early EN coupled with PN has not been evaluated. We conducted a double-blind, randomized, placebo-controlled study to assess the influence of adjuvant PN (Vitrimix KV, Pharmacia Upjohn) and early EN on the improvement of nutritional parameters, morbidity and mortality in the critically ill, excepted after elective surgery. Statistical analysis, in intention to treat, used parametric tests (chi-2, ANOVA). Two groups of 60 patients (EN + placebo versus EN + PN) have been enrolled: 82 males, 38 females, admitted for medical (51%) or 33 non elective surgical emergencies (49%), SAPS2 (42 ± 14), who were either normonourished (59%), moderate (32%) or severe undernourished (9%). On follow-up from D0 to D4, we observed a significant improvement in nutritional proteins (transthyretine, RBP, transferrine) in the treated group, but not from D0 to D7. Mortality on D90 was identical in both groups (17 vs 18) as were the number of days of ventilatory support (11 vs 10), the cumulative number of nosocomial infections (29 vs 30), the length of stay in intensive care (16.9 vs 17.3), the OSF score measured on D0, D4, D7, D14 and D21 and the OMEGA score (263 vs 244). In contrast, we observed a significant reduction in the number of days of inotropic support (3.8 vs 4.4, P = 0.0001) and the length of hospital stay (31.2 vs 33.7, P = 0.0022). These results suggest that a short PN coupled with early EN is safe, synergistic and cost-effective. By immediately achieving a minimum energetic uptake, it may provide the time necessary for EN to restore intestinal function.
Highlights
Lipopolysaccharides (LPS) are known to be involved in the pathogenesis of septic shock and multiorgan failure
Prospective, longitudinal, descriptive cohort study with no therapeutic interventions in which participated 63 patients admitted to the intensive care unit (ICU) with the clinical diagnosis of severe sepsis (21) or septic shock (42) [3] and 10 healthy adults that served as controls
This study shows for the first time that preoperative measurement of C-reactive protein (CRP) may offer a useful, predictive marker in risk stratification for postoperative infections in patients scheduled for cardiac surgery
Summary
Lipopolysaccharides (LPS) are known to be involved in the pathogenesis of septic shock and multiorgan failure. Conclusions: The combination of these two new and not very well known techniques, TGI and BIPAP, were useful in avoiding the adverse effects of high pressures and volumes to counteract the effects of high arterial CO2 levels in patients with limited cardio-circulatory status and acute or chronic lung and cerebral diseases In this small sample, considering the influence of time in the reduction of PACO2 and in the increase of pH values, the best moment to verify the response of TGI is beyond 60 min. Methods: 24 critically ill, MV patients (mean APACHE II score: 21, mean age 64 ± 14 yrs, 15 men), hospitalized in a medical intensive care unit, were prospectively included for 24-h esophageal pH and duodenogastroesophageal reflux (DGER) studies (Digitrapper III pH-meter and fiber-optic sensor for the presence of bilirubin, Bilitec 2000, Synectics, Sweden) with single sensors placed 5 cm proximal to the lower esophageal sphincter (LES) and instrumented with a nasogastric tube. Discussion and conclusion: The comparisons between institutions must be corrected for several factors: variations in casemix, patients co-morbidites, status of previous disease, delays in referral, social factors and access to
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