Nutrition Support for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome

Abstract

Despite tremendous advances in critical care, multiple-organ failure continues to be a significant problem. However, in recent years, far fewer patients with multiple-organ failure die early, but many experience ongoing immune dysregulation and are developing persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Most PICS patients are discharged to nonhome destinations, fail to rehabilitate, and succumb to indolent death. From a nutrition perspective, patients with PICS experience persistent inflammation-induced cachexia despite evidenced-based recommended intensive care unit nutrition support. Recent basic and translational research indicates that prolonged expansion of myeloid-derived suppressor cells plays a central role in the pathogenesis of PICS. Myeloid-derived suppressor cells express arginase 1, which depletes arginine, causing immunosuppression and impaired wound healing. This is the rationale for arginine supplementation in PICS. Other nutrition support recommendations for PICS are based on inferences made from other patient populations who experience similar persistent inflammation-induced cachexia. These include patients with established cancers, major burns, and sarcopenia. These patients experience anabolic resistance, but studies show that this can be overcome by providing higher levels of protein and certain specific amino acids. Nutrition support guidelines recommend provision of >1.5 g/kg/d of protein and indicate that higher levels may be needed. Protein composition is also important. There is good evidence that leucine can promote anabolism in patients with cancer and sarcopenia. Finally, anabolic interventions—including intensive insulin, oxandrolone, propranolol, and resistance exercise—have proven to be effective in patients with major burns and are likely relevant in combating PICS cachexia.

DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“

“…Kommentar: Für die "chronische Phase" (persistierende Organdysfunktion ohne akute inflammatorische/infektiöse Exazerbation) existieren bislang keine großen prospektiven Studien bei kritisch kranken Patienten [114,115]. Zur weitestmöglichen Konservierung des Muskeleiweißbestands und zur Unterstützung reparativer/immunologischer Prozesse bei diesen Langzeitpatienten ist eine kontinuierliche Ernährungstherapie erforderlich, die sich am sinnvollsten am gemessenen/geschätzten Energieumsatz orientiert (isokalorische Ernährung, 100 %).…”

Full Nutrition or Not?

“…In describing the persistent inflammation catabolism syndrome, Moore et al identified 3 potential pathways for patient outcome after admission to the ICU. The first pathway is rapid recovery, where the acute insult causes a systemic inflammatory response syndrome (SIRS) response, which is immediately opposed by the generation of a compensatory anti‐inflammatory response syndrome.…”

Increasing Enteral Protein Intake in Critically Ill Trauma and Surgical Patients

“…The response to surgical stress, trauma, and sepsis includes metabolic and physiologic changes that influence the inflammatory, acute phase, hormonal, and genomic responses . This is characterized by increased catabolism and leads to impaired immune function, poor wound healing, organ failure, nosocomial infection, muscle wasting, and death . Artificial nutrition support is an essential part of managing critically ill patients and is one of the most commonly used interventions in intensive care units (ICUs).…”

“…4,5 This is characterized by increased catabolism and leads to impaired immune function, poor wound healing, organ failure, nosocomial infection, muscle wasting, and death. 6 Artificial nutrition support is an essential part of managing critically ill patients and is one of the most commonly used interventions in intensive care units (ICUs). Clinical guidelines recommend that enteral nutrition should be the primary mode of support rather than parenteral nutrition and that it should be initiated within the first 24-48 hours following injury or admission.…”