Protective effect of glutamine in critical patients with acute liver injury

BACKGROUND:

Glutamine (Gln) supplementation is known to decrease oxidative stress and inflammatory response, enhance resistance to infectious pathogens, shorten hospital stay, and decrease medical costs of patients. This study was undertaken to evaluate the relationship between the effect of early parenteral glutamine (Gln) supplement on acute liver injury (ALI) and heat shock protein 70 (HSP-70) expression in critical patients.

METHODS:

Forty-four patients who had been admitted to the emergency intensive care unit (EICU) of Nanjing First Hospital Affiliated to Nanjing Medical University were randomly divided into a control group (n=22) and a Gln group (n=22). The patients of the two groups received enteral and parenteral nutrition. In addition, parenteral Gln 0.4 g/kg per day was given for 7 days in the Gln group. Serum HSP-70 and Gln were measured at admission and at 7 days after admission. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBiL), serum levels of HSP-70 and Gln, mechanical ventilation (MV) time, ICU stay, peripheral blood of TNF-α, IL-6, CD3, CD4 and CD4/CD8 levels were also measured in the two groups.

RESULTS:

In the Gln group, the levels of serum HSP-70 and Gln were significantly higher after Gln treatment than those before the treatment (P<0.01). HSP-70 level was positively correlated with the Gln level in the Gln group after administration of parenteral Gln (P<0.01). The levels of serum ALT, AST, TBiL and TNF-α, IL-6 were lower in the Gln group than in the non-Gln group (P<0.01). MV time and ICU stay were significantly different between the two groups (P<0.05). The levels of CD3, CD4 and CD4/CD8 were significantly higher in the Gln group than in the control group after treatment (P<0.05).

CONCLUSION:

Parenteral Gln significantly increases the level of serum HSP70 in critically ill patients. The enhanced expression of HSP70 is correlated with improved outcomes of Gln-treated patients with acute liver injury.KEY WORDS: Glutamine, Heat shock protein, Critically ill patients, Acute liver injury     

早期谷氨酰胺强化肠外营养对危重病患者体内热休克蛋白70的影响

目的探讨早期给予谷氨酰胺(Gln)强化肠外营养对危重病患者脏器功能的影响及其与预后的关系。方法选择本院急诊及神经外科重症加强治疗病房(NICU)收治的44例危重病患者,按随机原则分为常规治疗组和Gln治疗组,每组22例。两组患者均行肠内、外营养,同时Gln治疗组静脉注射Gln 0.4g·kg~(-1)·d~(-1),连用7d;观察两组患者治疗前后体内热休克蛋白70(HSP70)、Gln含量,机械通气时间、入住ICU时间及肝、肾功能不全的发生率。结果常规治疗组和Gln治疗组治疗前Gln、HSP70水平差异无显著性(P均>0.05);常规治疗组治疗后Gln、HSP70水平较治疗前稍有增加,但差异无显著性;而Gln治疗组治疗后Gln、HSP70水平均较治疗前显著升高,差异有显著性(P均<0.01),且两组治疗后Gln、HSP70水平比较差异均有显著性(P均<0.01)。Gln治疗组体内Gln浓度和HSP70含量的变化存在显著正相关(r=0.650 5,P=0.001)。两组机械通气时间和肝功能不全的发生率差异有显著性(P均<0.05),入住ICU的时间和肾功能不全的发生率则差异无显著性(P均>0.05)。结论给危重病患者早期肠外补充Gln能有效改善患者的预后,降低脏器功能不全的发生率,其机制可能与提高患者体内HSP70水平有关。     

Factors influencing caspofungin plasma concentrations in patients of a surgical intensive care unit

BACKGROUND: Co-morbidity, medical and surgical interventions often cause alterations to drug plasma concentrations and pharmacokinetic parameters in critically ill patients. In the present study, we investigated parameters influencing plasma caspofungin concentrations in patients of a surgical intensive care unit (SICU). METHODS: In a monocentre open study, caspofungin trough concentrations (C(24)) were determined for a group of SICU patients. A linear-mixed model was then used to assess factors influencing caspofungin plasma concentrations. RESULTS: A total of 40 SICU patients were enrolled. Age and body weight ranged from 22 to 76 years and 47 to 108 kg, respectively. All participants received a caspofungin loading dose of 70 mg and a maintenance dose of 50 mg/day. The median duration of therapy was 10 days. Caspofungin C(24) in SICU patients varied more than those determined for healthy subjects reported in previous studies (0.52-4.08 microg/mL versus 1.12-1.78 microg/mL). According to our model, caspofungin C(24) were predicted to be significantly higher in patients with body weight <75 kg (P=0.019) and patients with albumin concentration >23.6 g/L (P=0.030). CONCLUSIONS: Our results show that body weight and albumin concentration influence caspofungin C(24) in SICU patients and should therefore be considered prognostic factors.     

胃癌并发Hp感染患者血清miR-101，HSP-70，IL-1β表达水平与肿瘤增殖和侵袭力的相关性研究

目的　探讨胃癌并发幽门螺杆菌（Helicobacter pylori,Hp）感染患者血清miR-101,热休克蛋白-70（heat shock protein-70,HSP-70）和白细胞介素-1β（Interleukin-1β,IL-1β）表达水平与肿瘤增殖和侵袭力的相关性。方法　选取2017 年2 月~2020 年2 月绵阳市第三人民医院胃癌患者120 例为观察组( 依据Hp 检测结果分为胃癌Hp 阳性组68例、胃癌Hp 阴性组52 例)、同期慢性胃炎患者86 例为对照组。测定比较各组血清miR-101,HSP-70,IL-1β 水平和Hp 感染U 值,分析Hp 感染与胃癌患者血清各指标水平关联性,统计胃癌Hp 阳性组不同血清各指标水平患者胃癌组织中肿瘤增殖基因［磷脂酰肌醇-3 激酶催化亚基δ（phosphatidylinositol-3 kinase catalytic subunit δ,PIK3CD）、C-myc 癌基因（C-myc oncogene,C-myc）、zeste 基因增强子同源物2（zeste gene enhancer homolog 2,EZH2）]、侵袭基因[ 泛素样含PHD 和环指域1（Ubiquitin-like containing PHD and ring finger domain 1, UHRF1）及Vav3 癌基因（Vav3oncogene,Vav3）] 表达, 分析胃癌并发Hp 感染患者血清各指标水平与胃癌组织中肿瘤增殖、侵袭基因表达关系以及对患者生存率的影响。结果　胃癌Hp 阳性组血清miR-101 水平低于胃癌Hp 阴性组、对照组（0.51±0.13 vs 0.82±0.16,1.38±0.29）;HSP-70(2.73±0.69 pg/L vs 1.80±0.57 pg/L, 1.14±0.38 pg/L),IL-1β(42.07±18.54 pg/L vs 23.61±10.38 ng/L,16.37±7.09 ng/L) 水平和Hp 感染U 值(246.59±31.28 dpm/mmol vs 59.26±12.68 dpm/mmol, 41.35±8.39 dpm/mmol) 高于胃癌Hp 阴性组、对照组,差异均有统计学意义（F=79.650~2 297.784,均P ＜ 0.05）;Hp 感染U 值与胃癌Hp 阳性组患者血清miR-101（r ＝ -0.629）水平呈负相关,与HSP-70（r ＝ 0.574）和IL-1β（r ＝ 0.539）水平呈正相关（均P ＜ 0.05）;miR-101 高水平患者组织中PIK3CD,C-myc,EZH2,UHRF1 和Vav3 基因表达量均低于低水平患者,差异有统计学意义（t=8.554~17.034,均P ＜ 0.05）;HSP-70 高水平患者组织中各基因表达量均高于HSP-70 低水平患者,差异均有统计学意义（t=6.395~13.742,均P ＜ 0.05）;IL-1β 高水平患者组织中各基因表达量均高于IL-1β 低水平患者,差异有统计学意义（t=5.330~21.755,均P ＜ 0.05）。胃癌Hp 阳性患者血清miR-101 水平与组织中PIK3CD,C-myc,EZH2,UHRF1 和Vav3 基因表达量呈负相关(r=-0.664, -0.709, -0.714, -0.702, -0.687),HSP-70 和IL-1β 水平与组织中各基因表达量呈正相关（r=0.608~0.702, 均P ＜ 0.05）。随访至2021 年2 月,经Kaplan-Meier 生存分析显示,HSP-70和IL-1β 高水平胃癌Hp 阳性患者生存率均低于HSP-70 和IL-1β 低水平患者,miR-101 高水平患者生存率高于低水平患者,差异有统计学意义（χ2=8.163~9.862,均P ＜ 0.05）。结论　胃癌患者并发Hp 感染可诱导血清miR-101,HSP-70 和IL-1β 异常表达,促进肿瘤增殖和侵袭,影响患者预后。     

Combination enteral and parenteral nutrition in critically ill patients: harmful or beneficial? A systematic review of the evidence

Objective A combination of enteral (EN) and parenteral nutrition (PN) is often used as a strategy to optimize nutritional intake in critically ill patients; however, the effects of this intervention on clinically important outcomes have not been widely studied. This paper systematically reviewed studies that compare EN + PN to enteral nutrition (EN) alone in critically ill patients.Methods We searched bibliographic databases, personal files, and relevant reference lists to identify randomized controlled trials that compared combination EN + PN to EN alone.Results Only five studies met the inclusion criteria. In all these studies PN was started at the same time as EN in the experimental group. When the results of these trials were aggregated, EN + PN had no significant effect on mortality. There was no difference between the two groups in rates of infectious complications, length of hospital stay, or ventilator days.Conclusions In critically ill patients who are not malnourished and have an intact gastrointestinal tract, starting PN at the same time as EN provides no benefit in clinical outcomes over EN alone. More research is needed to determine the effects of combination EN + PN on clinical outcomes in critically ill patients who are poorly intolerant to EN.D.K.H. is a Career Scientist of the Ontario Ministry of Health     

Elevated asymmetric dimethylarginine levels predict short- and long-term mortality risk in critically ill patients

Objective

Serum concentrations of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, may contribute to endothelial dysfunction and organ failure in sepsis. We aimed at investigating ADMA levels as a potential diagnostic or prognostic biomarker in critically ill patients.

Methods

Two hundred fifty-five patients (164 with sepsis, 91 without sepsis) were studied prospectively upon admission to the medical intensive care unit (ICU) and on day 7, in comparison to 78 healthy controls. ADMA serum concentrations were correlated with clinical data and extensive laboratory parameters. Patients’ survival was followed up for up to 3 years.

Results

ADMA serum levels were significantly elevated in critically ill patients at admission compared to controls. ADMA levels did not differ between patients with or without sepsis, but were closely related to hepatic and renal dysfunction, metabolism and clinical scores of disease severity. ADMA levels further increased during the first week of ICU treatment. ADMA serum levels at admission were an independent prognostic biomarker in critically ill patients not only for short-term mortality at the ICU, but also for unfavorable long-term survival.

Conclusion

Serum ADMA concentrations are significantly elevated in critically ill patients, associated with organ failure and related to short- and long-term mortality risk.     

丙氨酰谷氨酰胺对急性肺损伤患者的保护作用及其机制初探

目的 观察丙氨酰谷氨酰胺(Ala-Gln)对急性肺损伤(ALI)患者的保护作用及其机制.方法 110例ALI患者随机分为对照组(50例)和Ala-Gln组(60例).对照组给予常规治疗,Ala-Gln组在常规治疗的基础上,加用Ala-Gln,疗程7天,分别观察两组间治疗前后血清谷氨酰胺(Gln)、热休克蛋白70(HSP70)水平、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)及机械通气时间的差异.结果 Ala-Gln组治疗后血清HSP70、Gln水平明显增高,与治疗前比较差异有统计学意义,HSP70 (1.99±0.66) μg/L vs (1.34±0.68) μg/L( P＜0.01);Gln (386.15±68.60)μg/L vs (304.72±73.70) μg/L(P＜0.01).与对照组治疗后比较差异亦有统计学意义,Gln (386.15±68.60) μg/L vs (303.74±78.08) μg/L( P＜0.01);HSP70 (1.99±0.66) μg/L vs(1.35±0.48)μg/L(P＜0.01).Ala-Gln组治疗前后Gln浓度比与HSP70浓度比呈明显正相关(r=0.809,P＜0.01),对照组治疗前后血清Gln、HSP70水平差异无统计学意义,对照组治疗前后Gln浓度比与HSP70浓度比无明显相关性(r=0.147,P＞0.05).Ala-Gln组机械通气时间明显低于对照组,(162.20±96.33)小时vs (235.00±107.90)小时(P＜0.05).治疗后APACHEⅡ评分的改善明显优于对照组,(8.40±2.17)分vs (11.10±2.42)分(P＜0.05).结论 Ala-Gln治疗可显著提高ALI患者血清Gln、HSP70水平、缩短机械通气时间,改善APACHEⅡ评分,提示Ala-Gln对ALI患者具有保护作用,其机制可能与提高患者体内Gln、HSP70水平有关.     

急性创伤患者血清总胆固醇浓度的临床评估

目的　探讨急性创伤患者血清总胆固醇浓度变化与伤情判断及预后的关系。方法　监测我院急救创伤科2 0 0 4年收治的急性创伤患者入院时、出院时血清总胆固醇浓度及血糖、白细胞等其他指标 ,并与健康体检组对比分析。结果　好转或痊愈的急性创伤患者出院时血清总胆固醇浓度明显高于入院时 (P <0 0 1) ,血糖和白细胞总数也有显著性差异 (P值分别是 <0 0 1、<0 0 0 1) ,入院后并发感染或器官功能障碍仍需住院的患者血清总胆固醇浓度在较低水平波动。结论　急性创伤后出现低胆固醇血症 ,随病情缓解而改善 ,若低胆固醇血症持续或进一步加重 ,预示着感染 ,胆固醇是比白细胞更敏感的感染指标。急性创伤患者应连续监测血清胆固醇浓度。     

Serum adiponectin upon admission to the intensive care unit may predict mortality in critically ill patients

Purpose

Adiponectin has been proposed as an important regulator of glucose metabolism influencing obesity and insulin resistance, which are important risk factors for the outcome of critically ill patients. Moreover, experimental models of inflammation suggest protective anti-inflammatory properties of adiponectin. We therefore investigated the potential pathogenic role and prognostic value of circulating adiponectin levels in critical illness.

Materials and methods

One hundred seventy critically ill patients (122 with sepsis and 48 without sepsis) were prospectively studied at admission to the medical intensive care unit (ICU) and compared with 60 healthy controls. Patients' survival was followed for approximately 3 years.

Results

Adiponectin serum concentrations did not differ between healthy controls and critically ill patients, neither in patients with nor in patients without sepsis. However, patients with decompensated liver cirrhosis had significantly elevated serum adiponectin levels. Likewise to non-critically ill subjects, ICU patients with preexisting diabetes or obesity displayed significantly reduced circulating adiponectin. Inflammatory cytokines did not correlate with serum adiponectin. Interestingly, low adiponectin levels at ICU admission were an independent positive predictor of short-term and overall survival.

Conclusions

Although serum concentrations did not differ in critically ill patients from controls, low adiponectin levels at admission to ICU have been identified as an independent predictor of survival.     

谷氨酰胺和生长激素强化营养对老年危重病患者免疫调理的影响

目的探讨联合应用谷氨酰胺和生长激素对老年危重病患者免疫调理的影响。方法90例患者采用前瞻、随机、对照的方法分为3组：A组为给予标准营养支持治疗对照组；B组为给予谷氨酰胺组；C组为联合应用谷氨酰胺和生长激素组。3组患者均于治疗前及治疗后7d和14d分别取血测定血清白蛋白、前白蛋白、C-反应蛋白（CRP）、免疫球蛋白G（IgG）的变化，外周血淋巴细胞总数、CD3、CD4、CD4／CD8及CD14单核细胞人白细胞DR抗原（CD14 HLA—DR）比例的变化。结果与A、B组比较，C组血清白蛋白、前白蛋白和IgG的水平均进一步提高，外周血淋巴细胞总数进一步增加，CD3、CD4、CD4／CD8及CD14 HLA—DR的表达水平均明显提高（P〈0．05或P％0．01）；炎症反应指标CRP明显下降（P均〈0．01）；急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分及多器官功能障碍综合征（MODS）评分均进一步下降（P〈0．05或P〈0．01）。3组患者重症监护室（ICU）住院时间、机械通气时间、28d生存率改变差异均无显著性（P均〉0．05）。结论联合应用谷氨酰胺和生长激素能促进老年危重病患者的蛋白合成，改善营养状况，改善免疫麻痹状态，下调炎症反应。     

Circulating cytokines and outcome prediction of burned children with concomitant inhalation injury

Being able to accurately predict probability of death is important for the intensivist. Serum cytokine levels parallel physiological derangements observed in critically ill patients and are used in commonly applied scoring systems and prediction models. Thus, serum cytokine based prediction models of outcome seem to be reasonable and of great interest. In this issue of Critical Care, Gauglitz and colleagues present their prediction equation for paediatric burn patients with concomitant inhalation injury. They found that IL-10 on admission, or IL-6 and IL-7 five to seven days later, may predict outcome in an excellent way. Increased mortality is observed as serum IL-6 and IL-10 levels increase and serum IL-7 levels decrease. However, the complexity of cytokine kinetics in critically ill patients and the variety of factors capable to affect circulating cytokines even in a subgroup of critically ill patients may affect the valitidy of the results. Also, serum cytokine based prediction models need to be compared to commonly applied prediction models based on clinical parameters. This will enable identification of the most suitable, accurate, cheapest, and easiest to use model to predict outcome.     

不同营养支持对危重病患者炎症介质及死亡率的影响

摘 要 目的 探讨不同营养支持方式对危重病患者炎症介质及死亡率的影响。方法 60例危重病患者分为试验组及对照组，每组各30例。30名健康体检者为正常组。试验组接受肠内营养(enteral nutrition, EN)+肠外营养（parenteral nutrition，PN）支持。对照组接受全肠外营养支持(total parenteral nutrition, TPN)，2组等氮等热量供给。营养支持前1天及营养支持后第10天检测血浆TNF-α及IL-10水平。并随访28天，观察两组死亡率。结果 试验组死亡率为26.7％，对照组死亡率为36.7％，两者相比无明显差异（P>0.05）。危重病患者血浆TNF-α及IL-10水平明显高于正常组(P< 0.05)；对照组及试验组治疗前的血浆TNF-α及IL-10水平比较，无明显差异（P>0.05）。营养支持后第10天，对照组及试验组的TNF-α及IL-10水平明显低于治疗前水平(P< 0.05)；试验组的TNF-α及IL-10水平明显低于对照组(P< 0.05)。结论 危重病患者存在炎症反应紊乱。PN+EN较TPN更能降低危重病人的炎症介质，减轻炎症反应，但不能降低死亡率。     

Hyaluronan serum concentrations are elevated in critically ill patients and associated with disease severity

ObjectivesThe matrix protein hyaluronic acid (HA, hyaluronan) has possibly additional immune-regulatory functions in inflammation. We aimed at evaluating serum HA concentrations in critically ill patients.Design and methodsWe analyzed serum HA levels in 164 critically ill patients at a medical ICU and 61 healthy controls, with respect to organ dysfunction, systemic inflammation and mortality.ResultsHyaluronan serum concentrations upon admission to ICU were significantly elevated in critically ill patients compared to healthy controls, with the highest levels in patients with pre-existing liver cirrhosis or sepsis. HA levels were closely correlated with biomarkers of hepatic and renal function, systemic inflammation, demand of treatment measures and clinical scores of disease severity, but could not predict risk of mortality.ConclusionsMeasurement of serum HA may supplement the assessment of disease severity in ICU patients. Our data suggest that HA might have implications in the pathogenesis of critical illness and sepsis.     

Polymorphisms of heat shock protein-70 (HSPA1B and HSPA1L loci) do not influence infection or outcome risk in critically ill surgical patients

Heat shock proteins (HSP) are induced in various stress conditions and have many cytoprotective effects, including formation of protein complexes for antigen presentation, stabilizing intracellular proteins, and facilitating protein folding. The HSP-70 gene exhibits polymorphisms at the HSPA1B and HSPA1L loci that reportedly influence cytokine levels and clinical outcomes in critically ill patients. These HSP variations also have been linked to TNF-beta polymorphisms associated with poor outcomes. This study further evaluated outcomes and risk of infection of HSP polymorphisms in critically ill patients. Seventy-six consecutive surgical intensive care unit uninfected patients with established systemic inflammatory response features were prospectively enrolled. Genomic DNA was isolated from whole blood samples and specific fragments, including the relevant polymorphic sites, were amplified by PCR, and restriction digestions were performed. Genotypes were determined by electrophoresis and all were confirmed by direct sequencing. Plasma cytokine levels for TNF-alpha were assayed in a subset of patients by enzyme-linked immunoabsorbent assay. None of the HSP alleles bore a significant relationship to nosocomial infection rates, organ specific dysfunctions, or mortality. No linkage of HSP genotype to common TNF-alpha or TNF-beta genotypes could be demonstrated, although the HSPA1L CT polymorphism was associated with higher levels of TNF-alpha compared with the TT genotype. These data suggest that polymorphisms of the HSPA1L or HSPA1B loci do not influence infection or other highly morbid outcomes in surgical intensive care unit patients.     

Serum resistin levels in critically ill patients are associated with inflammation, organ dysfunction and metabolism and may predict survival of non-septic patients

Introduction  

Blood glucose levels and insulin resistance in critically ill patients on admission to intensive care units (ICUs) have been identified as factors influencing mortality. The pathogenesis of insulin resistance (IR) in critically ill patients is complex and not fully understood. Resistin is a hormone mainly derived from macrophages in humans and from adipose tissue in rodents, which regulates glucose metabolism and insulin sensitivity. In non-critically ill patients, resistin was found to be related to impaired glucose tolerance, insulin resistance, metabolic syndrome, obesity and type 2 diabetes. Therefore, resistin might represent a link between inflammation, acute phase response and insulin resistance in critically ill patients. We aimed to examine the correlation of serum resistin concentrations to parameters of inflammation, organ function, metabolism, disease severity and survival in critically ill patients.     

Critical illness induces alternative activation of M2 macrophages in adipose tissue

Introduction

We recently reported macrophage accumulation in adipose tissue of critically ill patients. Classically activated macrophage accumulation in adipose tissue is a known feature of obesity, where it is linked with increasing insulin resistance. However, the characteristics of adipose tissue macrophage accumulation in critical illness remain unknown.

Methods

We studied macrophage markers with immunostaining and gene expression in visceral and subcutaneous adipose tissue from healthy control subjects (n = 20) and non-surviving prolonged critically ill patients (n = 61). For comparison, also subcutaneous in vivo adipose tissue biopsies were studied from 15 prolonged critically ill patients.

Results

Subcutaneous and visceral adipose tissue biopsies from non-surviving prolonged critically ill patients displayed a large increase in macrophage staining. This staining corresponded with elevated gene expression of "alternatively activated" M2 macrophage markers arginase-1, IL-10 and CD163 and low levels of the "classically activated" M1 macrophage markers tumor necrosis factor (TNF)-α and inducible nitric-oxide synthase (iNOS). Immunostaining for CD163 confirmed positive M2 macrophage staining in both visceral and subcutaneous adipose tissue biopsies from critically ill patients. Surprisingly, circulating levels and tissue gene expression of the alternative M2 activators IL-4 and IL-13 were low and not different from controls. In contrast, adipose tissue protein levels of peroxisome proliferator-activated receptor-γ (PPARγ), a nuclear receptor required for M2 differentiation and acting downstream of IL-4, was markedly elevated in illness. In subcutaneous abdominal adipose tissue biopsies from surviving critically ill patients, we could confirm positive macrophage staining with CD68 and CD163. We also could confirm elevated arginase-1 gene expression and elevated PPARγ protein levels.

Conclusions

Unlike obesity, critical illness evokes adipose tissue accumulation of alternatively activated M2 macrophages, which have local anti-inflammatory and insulin sensitizing features. This M2 macrophage accumulation may contribute to the previously observed protective metabolic activity of adipose tissue during critical illness.     

Serum adipocyte fatty acid-binding protein levels in patients with critical illness are associated with insulin resistance and predict mortality

Introduction

Hyperglycemia and insulin resistance are commonplace in critical illness, especially in patients with sepsis. Recently, several hormones secreted by adipose tissue have been determined to be involved in overall insulin sensitivity in metabolic syndrome-related conditions, including adipocyte fatty-acid binding protein (A-FABP). However, little is known about their roles in critical illness. On the other hand, there is evidence that several adipose tissue gene expressions change in critically ill patients.

Methods

A total of 120 patients (72 with sepsis, 48 without sepsis) were studied prospectively on admission to a medical ICU and compared with 45 healthy volunteers as controls. Various laboratory parameters and metabolic and inflammatory profiles were assessed within 48 hours after admission. Clinical data were collected from medical records.

Results

Compared with healthy controls, serum A-FABP concentrations were higher in all critically ill patients, and there was a trend of higher A-FABP in patients with sepsis. In multivariate correlation analysis in all critically ill patients, the serum A-FABP concentrations were independently related to serum creatinine, fasting plasma glucose, total cholesterol, TNF-alpha, albumin, and the Acute Physiology and Chronic Health Evaluation II scores. In survival analysis, higher A-FABP levels (> 40 ng/ml) were associated with an unfavorable overall survival outcome, especially in sepsis patients.

Conclusions

Critically ill patients have higher serum A-FABP concentrations. Moreover, A-FABP may potentially serve as a prognostic biomarker in critically ill patients with sepsis.     

Body iron status in critically ill patients: significance of serum ferritin

Serial measurements of blood haemoglobin, serum iron, serum transferrin, total iron-binding capacity, transferrin per cent saturation and serum ferritin were determined in 51 post-operative critically ill patients to investigate body iron status in severely stressed patients. The results showed decreased blood haemoglobin, serum iron, serum transferrin and transferrin saturation compared to an increase in serum ferritin levels. These results indicate that there is inadequate availability of iron to tissues (secondary to rearrangement of body iron to the advantage of the iron storage compartment), which is often present in severely critically ill patients. A positive correlation was found between the initial (ferritin) levels and SAPS (r=0.41,p< 0.01). In addition, the increase of ferritin concentration parallels a worsening of the clinical status in severely ill patients. This is due to enhanced release by the macrophage system. From this, we consider serum ferritin as an acute-phase protein and a useful marker of the severity of the clinical status. It appears to be useful in predicting the patient's outcome, but is not reliable in evaluating iron stores in stressed patients.     

Incidence of Inadequate Pain Treatment among Ventilated,Critically Ill Surgical Patients in a Thai Population

BackgroundInadequate pain treatment during intensive care unit stays causes many unfavorable outcomes. Pain assessment in mechanically ventilated patients is challenging because most cannot self-report pain. The incidence of pain among Thai surgical intensive care unit (SICU) patients has never been reported.AimsTo determine the inadequate pain control incidence among ventilated, critically ill, surgical patients.DesignProspective, observational study.SettingSICU of a university-based hospital during November 2017–January 2019.ParticipantsPatients aged > 18 years, admitted to the SICU for a foreseeable duration of mechanical ventilation > 24 hours were included.MethodsOn post-admission Day 2, each was assessed for pain at rest (every 4 hours) and during bed-bathing using the Critical Care Pain Observation Tool (CPOT; Thai version) or the 0–10 numeric rating scale (NRS). CPOT scores > 2 or NRS scores > 3 signified inadequate pain control, while a RASS score ≤ -3 was defined as overtreatment.Results118 were included. The inadequate-pain-management incidence was 34% (n = 40) at rest and 29% (n = 34) during bed-bathing. The severe-pain incidence (NRS > 6, or CPOT > 5) was 5.9% (n = 7). Our incidence of overtreatment was 1.7%. The demographic data and ICU complication-rates of patients with adequate and inadequate pain treatment were similar.ConclusionsPain assessment tools in critically ill patients should be developed and validated to the language of the tool users in order to determine the incidence of pain accurately. The inadequate-pain-treatment incidence in ventilated critically ill, Thai surgical patients was lower than previously reported from other countries.     

Erythrocyte zinc content in critically ill patients.

Abnormalities in thyroid hormone metabolism are common in critically ill patients. However, it is not known if these patients are truly hypothyroid at tissue level. Erythrocyte zinc has been shown to be a tissue marker of thyroid hormone status. In this study we have measured the erythrocyte zinc in critically ill patients. In this observational study we measured the zinc content of young erythrocytes in blood samples from 33 healthy subjects, 26 hypothyroid patients, four hyperthyroid patients, and 44 patients in the intensive care unit--22 of these were admitted after a major surgical procedure (surgical group) and the other 22 patients had a variety of conditions (non-surgical group). Erythrocytes were separated according to age by centrifugation. Plasma thyroid hormone concentrations were abnormal in 70% of the critically ill group. Erythrocyte zinc was significantly lower in hyperthyroid patients and higher in hypothyroid patients. In the non-surgical patients, erythrocyte zinc of young cells (median 256 micromol/L of cells) was significantly higher than (p<0.01) the corresponding cells in the healthy controls (202 micromol/L of cells), whereas in the surgical group it was not different (197 micromol/L of cells). We conclude that in non-surgical critically ill patients, erythrocyte zinc content is higher, suggesting that these patients may be hypothyroid at tissue level.