Probiotics in critically ill patients.

Madsen K.

J Clin Gastroenterol. 2008 Sep;42 Suppl 3 Pt 1:S116-8.

Severe sepsis with associated multisystem organ dysfunction is a leading cause of

death in patients hospitalized in intensive care units. The gastrointestinal

system plays a key role in the pathogenesis of multisystem organ dysfunction

owing to a breakdown of intestinal barrier function and increased translocation

of bacteria and bacterial components into the systemic circulation. During

critical illness, alterations occur in gut microflora owing to several factors,

including changes in circulating stress hormones, gut ischemia,

immunosuppression, the use of antibiotics, and lack of nutrients. The importance

of endogenous strains of probiotic bacteria such as Bifidobacterium and

Lactobacillus in maintaining intestinal barrier function and also in modulating

mucosal and systemic immune responses is becoming evident from numerous studies.

Bacteria in synbiotic (prebiotic and probiotic combinations) and probiotic

(mutistrain combinations) preparations are being used experimentally in the

treatment of acute pancreatitis, liver transplantation, and in trauma patients.

Recent studies have shown treatment of patients with multiple trauma or acute

pancreatitis with synbiotic preparations resulted in reduced rates of infection,

sepsis, and mortality in patients. Enterally fed patients in the intensive care

unit treated with a probiotic compound demonstrated enhanced immune function and

decreased incidence of diarrhea. Results from these clinical trials are

Encouraging, and warrant further investigation to clarify which probiotic

Bacterial strains are of most benefit to this population.

Benefits and risks of tight glucose control in critically ill adults: a

Meta-analysis.

JAMA. 2008 Aug 27;300(8):933-44.

Wiener RS, Wiener DC, Larson RJ.

CONTEXT: The American Diabetes Association and Surviving Sepsis Campaign

recommend tight glucose control in critically ill patients based largely on 1

trial that shows decreased mortality in a surgical intensive care unit. Because

similar studies report conflicting results and tight glucose control can cause

dangerous hypoglycemia, the data underlying this recommendation should be

critically evaluated. OBJECTIVE: To evaluate benefits and risks of tight glucose

control vs usual care in critically ill adult patients. DATA SOURCES: MEDLINE

(1950-2008), the Cochrane Library, clinical trial registries, reference lists,

and abstracts from conferences from both the American Thoracic Society

(2001-2008) and the Society of Critical Care Medicine (2004-2008). STUDY

SELECTION: We searched for studies in any language in which adult intensive care

patients were randomly assigned to tight vs usual glucose control. Of 1358

identified studies, 34 randomized trials (23 full publications, 9 abstracts, 2

unpublished studies) met inclusion criteria. DATA EXTRACTION AND ANALYSIS: Two

reviewers independently extracted information using a prespecified protocol and

evaluated methodological quality with a standardized scale. Study investigators

were contacted for missing details. We used both random- and fixed-effects models

to estimate relative risks (RRs). RESULTS: Twenty-nine randomized controlled

trials totaling 8432 patients contributed data for this meta-analysis. Hospital

mortality did not differ between tight glucose control and usual care overall

(21.6% vs 23.3%; RR, 0.93; 95% confidence interval [CI], 0.85-1.03). There was

also no significant difference in mortality when stratified by glucose goal ([1]

very tight: < or = 110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% CI, 0.77-1.04; or [2]

moderately tight: < 150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% CI, 0.83-1.18) or

intensive care unit setting ([1] surgical: 8.8% vs 10.8%; RR, 0.88; 95% CI,

0.63-1.22; [2] medical: 26.9% vs 29.7%; RR, 0.92; 95% CI, 0.82-1.04; or [3]

medical-surgical: 26.1% vs 27.0%; RR, 0.95; 95% CI, 0.80-1.13). Tight glucose

control was not associated with significantly decreased risk for new need for

dialysis (11.2% vs 12.1%; RR, 0.96; 95% CI, 0.76-1.20), but was associated with

significantly decreased risk of septicemia (10.9% vs 13.4%; RR, 0.76; 95% CI,

0.59-0.97), and significantly increased risk of hypoglycemia (glucose < or= 40

mg/dL; 13.7% vs 2.5%; RR, 5.13; 95% CI, 4.09-6.43). CONCLUSION: In critically ill

Date: 2016-01-05; view: 828