- Open Access
Imaging opens possibilities both to target and to evaluate nutrition in critical illness
© Rooyackers and Wernerman; licensee BioMed Central Ltd. 2014
- Published: 21 May 2014
Recently, a number of clinical trials have investigated the effect of nutrition in critical illness [1–4]. The results have been confusing rather than clarifying. Obviously there are difficulties in defining whether or not a specific patient is at a nutritional risk and also what should be the nutritional target in the early course of critical illness. The step from a nutritional intervention in the ICU to mortality outcomes is just too big and there is no well-known underlying mechanism. Not surprisingly, there are no prospective randomised studies demonstrating survival advantages in relation to nutrition.
Abdominal computed tomography scans, performed for other purposes, have been utilised in oncological patients to diagnose sarcopenia and to demonstrate the progress of sarcopenia over time [13, 14]. This concept is now transferred to critically ill patients in the ICU [15, 16], and in a recent report Weijs and colleagues reported a predictive value of sarcopenia during the ICU stay . In a subgroup within the Early Parenteral Nutrition Completing Enteral Nutrition in Adult Critically Ill Patients study, computed tomography scanning of the leg and abdomen was also used to assess the temporal loss of muscle tissue . Within that study the losses of leg muscle in repeated measurements were demonstrated to be useful to evaluate a nutritional intervention. The possibility to include objective measurements related to muscle wasting that are possible to handle in everyday clinical practice is an advancement in critical care medicine that should not be underestimated.
The limitation in using computed tomography scans in clinical practice today is that it involves patient transportation, which may involve medical risks and use of resources. Another track involving imaging and estimation of skeletal muscle mass, which easily can be brought to the bedside, is the use of ultrasound. Several investigators have demonstrated the use of ultrasound to monitor sarcopenia in critically ill patients over time . In a recent study, ICU patients were investigated with repeated ultrasound assessment of leg muscle . A relation between the severity of illness and the extent of the shrinkage of muscle cross-sectional area was reported. In addition, the report included biochemical data for protein content and protein kinetics in subgroups of patients in pllel to the imaging data. Although the report did not include any linking of the imaging by ultrasound to the biochemical alterations in skeletal muscle, which reflects the mechanisms behind the rather aggressive muscle depletion often seen in critical illness, the effort to present measurements obtainable on an everyday clinical basis to underlying mechanistic data is a conceptual breakthrough.
Today there are every few studies in which post-ICU muscle function is evaluated. Interesting pilot studies are at hand , but the limitation is often the difficulty to recruit a representative sample. There is an evolving literature over post-ICU quality of life in general, usually relying upon questionnaires that are well validated [27, 28]. Again, the limitation is most often the difficulty to recruit representative samples. Nevertheless, awareness of the difficulties involved means that the accuracy of results is improving over time. Imaging may be helpful in bridging the clinical finding during the ICU stay to functional status post-ICU. The link between sarcopenia during the ICU stay as a possible reflection of malnutrition and mortality outcome presented by Weijs and colleagues is a promising example in this direction .
The authors would like to acknowledge the support by grants from the Swedish Medical Research Council (projects 04210 and 14244) and the Country Council of Stockholm (projects 502033 and 511126), and the contributions from our entire working group described in detail online (http://www.icu-metabolism.se).
- Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, Van Cromphaut S, Ingels C, Meersseman P, Muller J, Vlasselaers D, Debaveye Y, Desmet L, Dubois J, Van Assche A, Vanderheyden S, Wilmer A, Van den Berghe G: Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011, 365: 506-517. 10.1056/NEJMoa1102662PubMedView ArticleGoogle Scholar
- Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O'Leary M, Solano T, Peake S, Early PN Investigators of the ANZICS Clinical Trials Group: Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013, 309: 2130-2138. 10.1001/jama.2013.5124PubMedView ArticleGoogle Scholar
- Heidegger CP, Berger MM, Thibault R, Zingg W, Pichard C: Supplemental parenteral nutrition in critically ill patients – authors’ reply. Lancet 2013, 381: 1716-1717.PubMedView ArticleGoogle Scholar
- Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, Morris A, Dong N, Rock P, National Heart Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network: Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012, 307: 795-803.PubMedView ArticleGoogle Scholar
- Gamrin L, Andersson K, Hultman E, Nilsson E, Essen P, Wernerman J: Longitudinal changes of biochemical pmeters in muscle during critical illness. Metabolism 1997, 46: 756-762. 10.1016/S0026-0495(97)90119-0PubMedView ArticleGoogle Scholar
- Gamrin L, Essen P, Forsberg AM, Hultman E, Wernerman J: A descriptive study of skeletal muscle metabolism in critically ill patients: free amino acids, energy-rich phosphates, protein, nucleic acids, fat, water, and electrolytes. Crit Care Med 1996, 24: 575-583. 10.1097/00003246-199604000-00005PubMedView ArticleGoogle Scholar
- Larsson L, Li X, Edstrom L, Eriksson LI, Zackrisson H, Argentini C, Schiaffino S: Acute quadriplegia and loss of muscle myosin in patients treated with nondepolarizing neuromuscular blocking agents and corticosteroids: mechanisms at the cellular and molecular levels. Crit Care Med 2000, 28: 34-45. 10.1097/00003246-200001000-00006PubMedView ArticleGoogle Scholar
- Petersson B, Hultman E, Andersson K, Wernerman J: Human skeletal muscle protein: effect of malnutrition, elective surgery and total parenteral nutrition. Clin Sci 1995, 88: 479-484.PubMedView ArticleGoogle Scholar
- Essen P, McNurlan MA, Gamrin L, Hunter K, Calder G, Garlick PJ, Wernerman J: Tissue protein synthesis rates in critically ill patients. Crit Care Med 1998, 26: 92-100. 10.1097/00003246-199801000-00022PubMedView ArticleGoogle Scholar
- Gamrin L, Berg HE, Essen P, Tesch PA, Hultman E, Garlick PJ, McNurlan MA, Wernerman J: The effect of unloading on protein synthesis in human skeletal muscle. Acta Phys Scand 1998, 163: 369-377. 10.1046/j.1365-201X.1998.t01-1-00391.xView ArticleGoogle Scholar
- Gamrin L, Essen P, Hultman E, McNurlan MA, Garlick PJ, Wernerman J: Protein-sparing effect in skeletal muscle of growth hormone treatment in critically ill patients. Ann Surg 2000, 231: 577-586. 10.1097/00000658-200004000-00018PubMedPubMed CentralView ArticleGoogle Scholar
- Tjader I, Rooyackers O, Forsberg AM, Vesali RF, Garlick PJ, Wernerman J: Effects on skeletal muscle of intravenous glutamine supplementation to ICU patients. Intensive Care Med 2004, 30: 266-275. 10.1007/s00134-003-2048-9PubMedView ArticleGoogle Scholar
- Baracos VE, Reiman T, Mourtzakis M, Gioulbasanis I, Antoun S: Body composition in patients with non-small cell lung cancer: a contemporary view of cancer cachexia with the use of computed tomography image analysis. Am J Clin Nutr 2010, 91: 1133S-1137S. 10.3945/ajcn.2010.28608CPubMedView ArticleGoogle Scholar
- Mourtzakis M, Prado CM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE: A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab 2008, 33: 997-1006. 10.1139/H08-075PubMedView ArticleGoogle Scholar
- Braunschweig CA, Sheean PM, Peterson SJ, Perez SG, Freels S, Troy KL, Ajanaku FC, Patel A, Sclamberg JS, Wang Z: Exploitation of diagnostic computed tomography scans to assess the impact of nutritional support on body composition changes in respiratory failure patients. JPEN J Parenter Enteral Nutr 2013. Epub ahead of print 2013. Aug 23, doi 10.1177/0148607113500505Google Scholar
- Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, Bulger E, Kozar RA, Nutrition and Rehabilitation Investigators Consortium: Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care 2013, 17: R206. 10.1186/cc12901PubMedPubMed CentralView ArticleGoogle Scholar
- Weijs PJ, Looijaard WG, Dekker IM, Stapel SN, Girbes AR, Oudemans-van Straaten HM, Beishuizen A: Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Crit Care 2014, 18: R12. 10.1186/cc13189PubMedPubMed CentralView ArticleGoogle Scholar
- Casaer MP, Langouche L, Coudyzer W, Vanbeckevoort D, De Dobbelaer B, Guiza FG, Wouters PJ, Mesotten D, Van den Berghe G: Impact of early parenteral nutrition on muscle and adipose tissue compartments during critical illness. Crit Care Med 2013, 41: 2298-2309. 10.1097/CCM.0b013e31828cef02PubMedView ArticleGoogle Scholar
- Reid CL, Campbell IT, Little RA: Muscle wasting and energy balance in critical illness. Clin Nutr 2004, 23: 273-280. 10.1016/S0261-5614(03)00129-8PubMedView ArticleGoogle Scholar
- Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS, Velloso C, Seymour J, Agley CC, Selby A, Limb M, Edwards LM, Smith K, Rowlerson A, Rennie MJ, Moxham J, Harridge SD, Hart N, Montgomery HE: Acute skeletal muscle wasting in critical illness. JAMA 2013, 310: 1591-1600. 10.1001/jama.2013.278481PubMedView ArticleGoogle Scholar
- Fredriksson K, Tjader I, Keller P, Petrovic N, Ahlman B, Scheele C, Wernerman J, Timmons JA, Rooyackers O: Dysregulation of mitochondrial dynamics and the muscle transcriptome in ICU patients suffering from sepsis induced multiple organ failure. PLoS ONE 2008, 3: e3686. 10.1371/journal.pone.0003686PubMedPubMed CentralView ArticleGoogle Scholar
- Klaude M, Mori M, Tjader I, Gustafsson T, Wernerman J, Rooyackers O: Protein metabolism and gene expression in skeletal muscle of critically ill patients with sepsis. Clin Sci (Lond) 2012, 122: 133-142. 10.1042/CS20110233View ArticleGoogle Scholar
- Klaude M, Fredriksson K, Hammarqvist F, Ljungqvist O, Wernerman J, Rooyackers O: Proteasome proteolytic activity increases in leg and intercostal muscle during critical illness. Clin Nutr 2005, 24: 572.View ArticleGoogle Scholar
- Klaude M, Fredriksson K, Tjader I, Hammarqvist F, Ahlman B, Rooyackers O, Wernerman J: Proteasome proteolytic activity in skeletal muscle is increased in patients with sepsis. Clin Sci (Lond) 2007, 112: 499-506. 10.1042/CS20060265View ArticleGoogle Scholar
- Bierbrauer J, Koch S, Olbricht C, Hamati J, Lodka D, Schneider J, Luther-Schroder A, Kleber C, Faust K, Wiesener S, Spies CD, Spranger J, Spuler S, Fielitz J, Weber-Carstens S: Early type II fiber atrophy in intensive care unit patients with nonexcitable muscle membrane. Crit Care Med 2012, 40: 647-650. 10.1097/CCM.0b013e31823295e6PubMedView ArticleGoogle Scholar
- Poulsen JB, Moller K, Jensen CV, Weisdorf S, Kehlet H, Perner A: Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock. Crit Care Med 2011, 39: 456-461. 10.1097/CCM.0b013e318205c7bcPubMedView ArticleGoogle Scholar
- Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM, Canadian Critical Care Trials Group: Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011, 364: 1293-1304. 10.1056/NEJMoa1011802PubMedView ArticleGoogle Scholar
- Griffiths J, Hatch RA, Bishop J, Morgan K, Jenkinson C, Cuthbertson BH, Brett SJ: An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Crit Care 2013, 17: R100. 10.1186/cc12745PubMedPubMed CentralView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.