Nutritional support strategies for patients with PICS guided by indirect energy assays
Editor's Note
All scientific progress and development are inseparable from the role of innovation, and medicine is even more so... I remember that Professor Kwong Ankun, the founder of the Department of Internal Medicine of Ruijin Hospital, once said, "Do learning, don't just do what people have done." ”
Yes, the courage to innovate is the spiritual core of all Ruijin people, and for a hundred years they have insisted on improving the scientific research system and insisting on writing innovative results on the patient's health book. Starting today, we will launch a series of reports on "Ruijin Medical Techniques" to deeply reveal these cutting-edge technologies...
01.
For severely ill patients who have been bedridden for a long time, it is difficult for you to find "fat people". For example, Xiao Wang from Zhejiang, he is lying in the ICU ward, he has a plastic tube inserted in him, the plastic tube is placed in the trachea through the mouth and vocal cords, and a machine next to him is sending air into his lungs.
Xiao Wang lay quietly, but his heart rate reached 120 beats per minute, and he maintained his blood pressure with the help of vasopressors.
In fact, in the past 3 months, he had repeated bloodstream infections and pneumonia, and the situation deteriorated. How can we save the life of this 26-year-old?
Xiao Wang had 3 years of repeated thyroid diseases, but there was no clear diagnosis, watching the neck become thicker and thicker, the eyes became more and more prominent, and by 3 months ago, he had high fever, sweating and cardiogenic shock. After several turns, he was finally diagnosed with hyperthyroidism and thyroid crisis at Ruijin Hospital, but the delayed condition made his treatment extremely difficult.
Although drugs for the treatment of hyperthyroidism can be used, long-term consumption makes Xiao Wang's immune system poor and weak, and his skinny physique, muscle atrophy, low immunity, and more repeated experience of fungal and drug-resistant bacteria infections will be a bad vicious circle.
How to interrupt such a cycle is a very difficult problem facing the treatment team.
02.
Xiao Wang's condition is no longer the traditional critical illness course that we commonly see, that is, the course of gradual recovery after the blow of an acute severe disease; but has evolved into a state of repeated inflammatory blows after an acute severe blow, and its consumption is longer and more intense, for its body.
Like a person who has been crushed, the blow cannot arouse his fighting spirit, but he will wear down his will step by step until he dies. This state is called persistent inflammation – immunosuppression – catabolism syndrome (PICS). Such a long-lasting critical state is called chronic critical illness.
PICS is a critical illness state that has gradually attracted attention from the critical illness community in recent years, and its overall treatment strategy is still small, but with the aging of the population, more chronic diseases and other states, the medical burden brought by PICS is particularly worthy of attention. Such patients often consume a lot of resources but struggle to obtain a satisfactory outcome.
In xiao wang's course, the first thing is to control his hyperthyroidism and reduce the patient's consumption. The use of hyperthyroidism drugs, the use of sedative and analgesic drugs, body temperature control, and the adjustment of water electrolytes can control Xiao Wang's consumption.
Another important step is to increase his anabolic metabolism. On the one hand, it is necessary to give Xiao Wang sufficient nutritional raw materials, on the other hand, it is necessary to make nutrition efficiently transformed. Among them, another challenge is that Xiao Wang is in a long period of intense nutrient consumption, and if too much nutrition is given at the beginning, it may bring "refeed syndrome" and thus "pull up seedlings".
Therefore, for Xiao Wang, the amount of in and out, step by step is the most reasonable treatment strategy, and the refined measurement is the premise. At the same time, in PICS, after the control of the primary disease is completed, it is very important to remodel the patient's immune state, and among them, nutritional therapy is an important measure to remodel immunity.
So the treatment team adopted the strategy of indirect energy measurement to develop a delicate nutritional support program for Xiao Wang, including a reasonable ratio of sugar, fat, and protein. At the same time, Xiao Wang's daily demand and consumption of oxygen are measured to clarify the quantitative relationship between consumption and supply, so as to achieve the strategy of supply > consumption. By observing and mediating Xiao Wang's gastrointestinal function status daily, it is ensured that he is safe to carry out adequate enteral nutrition.
After such delicate treatment, Xiao Wang's hyperthyroidism and infection were controlled, and his anabolic metabolism gradually strengthened, and he was finally transferred out of the intensive care unit and transferred to the general ward to continue rehabilitation.
03.
In the field of critical care medicine, precision treatment based on data is an important treatment concept, and indirect energy measurement provides a feasible method for the clinical realization of accurate supply of energy substances, and is also the gold standard for clinical energy metabolism measurement. In practice, many critically ill patients have benefited from this precision treatment strategy.
The Department of Critical Care Medicine of Ruijin Hospital is currently ranked sixth in The country and first in Shanghai on the Fudan rankings. On the basis of improving the original circulatory and respiratory support system, the department pays more attention to the long-term quality of life and rehabilitation of critically ill patients. In recent years, special attention has been paid to the occurrence and impact of nutritional therapy and PICS in critically ill patients, and the use of indirect energy assays to guide the precise use of nutrition in PICS patients has won the 2021 Guangci Innovation Award.
(Swipe up to view)
Author: Zhong Ming
Editor: Li Dong