Persistent, Immunosuppression, Inflammation, Catabolism Syndrome and Diaphragmatic Dysfunction

Rosenthal, Martin D.; Rosenthal, Cameron M.; Moore, Frederick A.; Martindale, Robert G.

doi:10.1007/s13665-017-0166-z

Cited by 16 publications

(10 citation statements)

References 30 publications

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“…10 Most of these patients, if not all, were observed to lose tremendous amounts of lean body mass despite optimal nutrition, causing profound weakness (catabolism), suffer from recurrent nosocomial infections (immunosuppression), typically develop decubitus ulcers, have poor wound healing, have sepsis recidivism, and ultimately experience poor long-term outcomes. [8][9][10]18 A recent report by Puthucheary et al 19 demonstrated the basis of ICUAW associated with CCI. In this prospective observation trial of 63 critically ill patients with an average APACHE II (Acute Physiology and Chronic Health Evaluation II) score of 23.5, the authors found that the rectus femoris cross-sectional area (CSA) decreased on average 17.7% by day 10, and the ratio of protein to DNA decreased by 29.5%.…”

Section: The Cci/pics Clinical Trajectorymentioning

confidence: 99%

“…Among these entities are ICU‐acquired weakness (ICUAW), diaphragm dysfunction associated with prolonged mechanical ventilation, and PICS . Most of these patients, if not all, were observed to lose tremendous amounts of lean body mass despite optimal nutrition, causing profound weakness (catabolism), suffer from recurrent nosocomial infections (immunosuppression), typically develop decubitus ulcers, have poor wound healing, have sepsis recidivism, and ultimately experience poor long‐term outcomes . A recent report by Puthucheary et al demonstrated the basis of ICUAW associated with CCI.…”

Section: The Cci/pics Clinical Trajectorymentioning

confidence: 99%

“…CCI and PICS both represent patients with aberrant immunology where homeostasis is not achieved and dysfunction persists. These patients with CCI experience ongoing immunosuppression (eg, lymphopenia), inflammation (eg, neutrophilia with elevated acute‐phase response proteins), and significant lean muscle mass wasting associated with catabolism …”

Section: Introductionmentioning

confidence: 99%

“…These patients with CCI experience ongoing immunosuppression (eg, lymphopenia), inflammation (eg, neutrophilia with elevated acute-phase response proteins), and significant lean muscle mass wasting associated with catabolism. [8][9][10] Unfortunately, PICS is the consequence of optimal evidence-based ICU care, and currently the therapies to prevent or treat CCI and PICS are limited. Given the complex and persistent nature of the underlying dysregulated immunity, multimodality treatment will be required that will need to be extended beyond hospitalization to enhance rehabilitation.…”

Section: Introductionmentioning

confidence: 99%

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Chronic Critical Illness: Application of What We Know

et al. 2018

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Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.

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Section: The Cci/pics Clinical Trajectorymentioning

confidence: 99%

Section: The Cci/pics Clinical Trajectorymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Chronic Critical Illness: Application of What We Know

et al. 2018

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“…Indeed, roughly 5%–10% of intensive care unit (ICU) survivors transition to chronic critical illness (CCI), including a phenotype recently described as persistent inflammation, immunosuppression, and catabolism syndrome (PICS) . Both CCI and PICS are associated with poor long‐term outcomes and are often accompanied by severe limitations in daily functioning as well as continued dependence on many intensive care resources outside of the acute care setting . Functional status at discharge has been shown to be a strong predictor of short‐term and long‐term morbidity as well as mortality in hospitalized patients .…”

Section: Introductionmentioning

confidence: 99%

Admission 25‐Hydroxyvitamin D Levels Are Associated With Functional Status at Time of Discharge from Intensive Care Unit in Critically Ill Surgical Patients

et al. 2018

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Background: Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU). Methods: In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission. Results: Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (β = .20; 95% CI 0.14-0.25). Patients with 25OHD levels <20 ng/mL had >3-fold risk of low FSS-ICU (<17) compared with patients with 25OHD >20 ng/mL (OR 3.45; 95% CI 1.96-6.08). Conclusions: Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients. (Nutr Clin Pract. 2019;34:572-580) Keywords critical illness; fatigue; functional status; intensive care unit; vitamin D; vitamin D deficiency From the

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Chronic Critical Illness Patients Fail to Respond to Current Evidence‐Based Intensive Care Nutrition Secondarily to Persistent Inflammation, Immunosuppression, and Catabolic Syndrome

Rosenthal

Bala

Wang

et al. 2020

J Parenter Enteral Nutr

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Background Sepsis‐induced multiple‐organ failure (MOF) has plagued surgical intensive care units (ICUs) for decades. Early nutrition (principally enteral) improves hospital outcomes of high‐risk ICU patients. The purpose of this study is to document how the growing epidemic of chronic critical illness (CCI) patients responds to adequate evidence‐based ICU nutrition. Methods This retrospective post hoc subgroup analysis of an ongoing sepsis database identified 56 CCI patients who received early, adequate nutrition per an established surgical ICU protocol compared with 112 matched rapid‐recovery (RAP) patients. Results The matched CCI and RAP groups had similar baseline characteristics. Serial biomarkers showed that CCI patients remained persistently inflamed with ongoing stress metabolism and that despite receiving evidence‐based protocol nutrition, they had persistent catabolism and immunosuppression with more secondary infections. More CCI patients were discharged to poor nonhome destinations (ie, skilled nursing facilities, long‐term acute care, hospice) (81% vs 29%, P < 0.05). At 12‐month follow‐up, CCI patients had worse functional status by Zubrod score (3.17 vs 1.62, P < 0.001) and Short Physical Battery Testing (4.78 vs 8.59, P < 0.02), worse health‐related quality of life by EQ‐5D‐3L descriptive measures (9.07 vs 7.45, P < 0.003), and lower survival (67% vs 92%, P < 0.05). Conclusions Despite early, adequate, evidence‐based ICU nutrition, septic surgical ICU patients who develop CCI exhibit persistent inflammation, immunosuppression, and catabolism with unacceptable long‐term morbidity and mortality. Although current evidence‐based ICU nutrition may improve short‐term ICU outcomes, novel adjuncts are needed to improve long‐term outcomes for CCI patients.

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Persistent, Immunosuppression, Inflammation, Catabolism Syndrome and Diaphragmatic Dysfunction

Cited by 16 publications

References 30 publications

Chronic Critical Illness: Application of What We Know

Chronic Critical Illness: Application of What We Know

Admission 25‐Hydroxyvitamin D Levels Are Associated With Functional Status at Time of Discharge from Intensive Care Unit in Critically Ill Surgical Patients

Chronic Critical Illness Patients Fail to Respond to Current Evidence‐Based Intensive Care Nutrition Secondarily to Persistent Inflammation, Immunosuppression, and Catabolic Syndrome

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