Current opinion in critical care
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Glucagon is known as a key hormone in the control of glucose and amino acid metabolism. Critical illness is hallmarked by a profound alteration in glucose and amino acid metabolism, accompanied by muscle wasting and hypoaminoacidemia. Here we review novel insights in glucagon (patho)physiology and discuss the recently discovered role of glucagon in controlling amino acid metabolism during critical illness. ⋯ Glucagon plays a crucial role in amino acid metabolism during critical illness, with an apparent feedback loop between glucagon and circulating amino acids. Indeed, elevated glucagon may, to a large extent, be responsible for the hypoaminoacidemia in the critically ill and infusing amino acids increases glucagon-driven amino acid breakdown in the liver. These novel insights further question the rationale for amino acid administration during critical illness.
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Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. ⋯ TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.
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Curr Opin Crit Care · Aug 2018
ReviewNutritional support in patients with extracorporeal life support and ventricular assist devices.
Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD. ⋯ Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.
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To provide an overview of recent findings concerning refeeding syndrome (RFS) among critically ill patients and recommendations for daily practice. ⋯ RFS is a potentially life-threatening condition induced by initiation of feeding after a period of starvation. Although a uniform definition is lacking, most definitions comprise a complex constellation of laboratory markers (i.e. hypophosphatemia, hypokalemia, hypomagnesemia) or clinical symptoms, including cardiac and pulmonary failure. Recent studies show that low caloric intake results in lower mortality rates in critically ill RFS patients compared with RFS patients on full nutritional support. Therefore, standard monitoring of RFS-markers (especially serum phosphate) and caloric restriction when RFS is diagnosed should be considered. Furthermore, standard therapy with thiamin and electrolyte supplementation is essential.
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Full nutritional support during the acute phase of critical illness has traditionally been recommended to reduce catabolism and prevent malnutrition. Approaches to achieve full nutrition include early initiation of nutritional support, targeting full nutritional requirement as soon as possible and initiation of supplemental parenteral nutrition when enteral nutrition does not reach the target. ⋯ A two-phase approach for nutritional support may more appropriately account for the physiologic changes during critical illness than one-phase approach. Further evidence is awaited for the optimal protein amount during critical illness and for feeding patients at high nutritional risk or with acute gastrointestinal injury.