Comprehensive summary

#ISICEM-Course on Metabolic and Nutritional Issues 

in the ICU.

Day1

Today was the first day of the advance metabolic and nutritional ICU course, were world-wide experts debated on critical issues of daily ICU management. Authors come from different countries such as Belgium, France, Sweden, Netherlands, Germany and Switzerland.
Here we present a comprehensive summary of todays key messages from each speaker.




Metabolic response to stress. 
Dr. Jean-Charles Preiser (Brussels, Belgium)
"Homeostasis is needed for life"
During critical illness, circulating levels of orixigenic hormones (gherlin), are reduced. Also,  circulating levels of anorexigenic levels (PYY), are elevated.

The benefits and risks of insulin resistance.
Dr. Peter Soeter (Maastricht, Netherlands)
"The brain does not rely exclusively on glucose"
In critically ill patients, a target blood blood glucose level of 10 mmol (180 mg/dL). Lower levels increase the risk of hypoglycemia and decreases the host response to injury. With 50% of energy requirements covered by glucose, this risk is diminished in host response promoted.

Protein catabolism.
Dr. Jan Wernerman (Stockholm, Sweden).
" Techniques to asses protein metabolism have inherent limitations".
During critical illness, protein catabolism is unevenly distributed in between organs. This means that protein stores  could not be use to maintain homeostasis. However, measurement of proteins metabolism during critical illness is related to measurement biases.











Anabolic resistance
Dr. Jean-Paul Thissen (Brussels, Belgium)
"We should try to increase anabolic stimulus and decrease the resistance threshold"
Anabolic resistance was defined as the inability of skeletal muscle to respond to anabolic stimuli by stimulating protein synthesis and inhibiting proteolysis. There are several factors associated with increase  anabolic resistance such as age, inflammation, cancer, splachnic sequestration and micro-vascular alterations.

Autophagy
Dr. Michael Casaer ( Leuven, Belgium)
" Suppression of Autophagy was associated with organ failure"
Unfortunately, results from a animal studies depicting the role of autophagy have been un-conclusive. More data is needed to understand the role of this highly preserved pathway during critical illness.

Gastrointestinal dysfunction
Alain-Michel Dive (Yvoir, Belgium)
"Patients in the ICU have abnormal inter digestive migratory motor complex function and are not able to start a normal feeding pattern".
Patients that are mechanically ventilated have abnormal retrograde duodenal bolus propagation with almost zero activity at the gastric level. This increase the risk of ileus and broncho-inhalation.

Management of gastric residual volumes
Dr. Jean Reignier (La Roche Sur Yon, France)
"The myth of gastric volume"
Gastric residual volume monitoring should be removed from the standard of care of critically ill patients receiving mechanical ventilation and early enteral nutrition.

Measurements of energy expenditure
Dr. Elisabth de Waele (Brussels, Belgium)
Formulas for estimating the caloric need of critically ill patients are not reliable. Theses formulas may over-estimate the caloric need and thus increase the risk of over-feeding.
However, indirect calorimetry can be performed in only 50% of patients in the ICU, and technical issues make this technique also difficult to perform.

Protein turn-over
Dr. Jan Wernerman (Stockholm, Sweeden)
" The use of protein turnover measurements has the potential to guide protein feeding to critically ill patients"

Assessment of body composition
Dr. Claude Pichard (Geneva, Switzerland)
"It is almost impossible to measure body composition in ICU patients".
Assessment of body composition by CT-scan or MRI could correlate with nutritional risk and outcome. It could reflect the efficiency of nutrition support and thus allow to tailor treatment to patient´s characteristics.








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