Title: Perioperative care for the older patient with malnutrition Stig Bengmark MD PhD University College,
1Perioperative care for the older patient with
malnutrition Stig Bengmark MD PhDUniversity
College, UCL, London
- Best clinical practice L5
- Erasmus University, Rotterdam
- March 27-29 2008
-
FREE ACCESS!
2AGING A HORMONAL CHAOS
- Senescence - a multiple hormone
- deficiency syndrome, accompanied by
- Excessive free radical formation
- Glycation cross-linking of proteins
- Imbalanced apoptosis system
- Accumulation of waste products
- Poor cell proliferation failure of repair
- Deficient immune system
Hertoghe T Ann NY Acad Scien
20051017448-465
3AGING CHARACTERISTICS
- Poor gene polymorphisms
- Premature telomere shortening
- Poor chaperone expression
- Activation of various genetic factors
- Accelerated by lifestyle factors behavioural,
dietary environmental conditions, which
aggravate aging
enhancing development of acute and chronic
diseases
4AGING BARRIER FUNCTION
- Changes of microbiota composition
- Deficient protective commensals
- Deficient epithelial integrity
- Reduced barrier components sIgA, mucins,
defensins, gastric acid etc and often - Chronic activation of the immune systems by
persistent viral infections, in particular
cytomegalovirus (CMV) - CMV infections, esp. in the elderly, associated
to changes of T cell immunity gt low ratio
naive/memory T cells. - Vasto S et al. Immun Ageing 200632.
5AGING ORGAN FUNCTION After Hertoghe T Ann NY
Acad Scien 20051017448-465
6SINGLE ORGAN FAILURE
- Example severe acute pancreatitis
- Lungs 81 - 91
- Kidneys 4.5 - 5
- Coagulation 4.5 - 14
- McKay CJ, Buter A 20033111-114
- Johnson CD, Abu-Hilal M Gut 2004531340 -1344
-
7THE DUTCH HOSPITAL PATIENT (AMS)
- 34 of general ward patients are malnourished (P
0.05) - Only half (54) identified by staff
- Have in average 2 chronic diseases
- Little information to general practitioner (GP)
in discharge letters. 3 months after discharge,
most GPs are not aware of any nutritional
problems van Bokhorst-de van der Schueren MA et
al.
Eur J Clin Nutr 2005591129-1135
8THE MALNOURISHED PATIENT (USA)
- App 50 increase in length of stay also in
ICUs - App 50 higher hospital costs
- Higher complication rates
- Use app 3 times as much of home care facilities
Chima CS et al J Am Diet Assoc. 1997
Sep97(9)975-8
9PROTEIN MALNUTRITION (PEM) IN BURNS(USA
Harvard)
- PEM present in 61
- - Increased infection rate,
- Decreased rate of healing - Mortality
- with PEM 17 without
PEM 9
Demling RH. J Burn Care Rehabil
20052694-100
10PREDICTION OF POSTOPERATIVE OUTCOME IN MAJOR
SURGERY
- The odds ratio for morbidity between well
nourished and malnourished patients is - 2.30 (CI 1.43-3.71) - Maastricht Index
- 2.81 (CI 0.79-9.95) - Mini Nutritional
Assessment - 3.09 (CI 1.96-4.88) - Subjective Global
Assessment - 3.47 (CI 2.12-5.68) - Nutritional Risk Index
- Kuzu MA et al. World J Surg 200630378-390
-
11A MOTHER OF DISEASE
Bengmark S. J Clin Nutr
2004231256-1266
12INFLAMMATION PRECEDES INFECTION
- Superinflammation precedes and paves the way for
the subsequent disease incl infections - the challenge in critical illness is less the
infection than the exuberant inflammatory
response
Taneja et al Crit Care Med
2004 32 14601469
13KATRINA OF SEPSIS (USA)
- 751000 each year treated for severe sepsis
- 215 000 deaths
- Increases by 15
per decade - 10th commonest cause of death in USA
- Angus DC, Wax RS (2001) Crit Care Med
200129109
14SYSTEMIC INFLAMMATION IN ELDERLY
- Many elderly with yet no obvious disease
demonstrate - higher levels of serum inflammatory proteins
C-reactive protein, fibrinogen, factor VIII
activity, interleukin-6 and TNF-a - are candidates to develop chronic diseases
complications to disease - Finch CE, Crimmins EM. Science 2004 30517361739
15INFLAMMATION PHYSICAL PERFORMANCE
- Chronic inflammation key to decline in
physical function in elderly people - Physical performance (PP) is significantly
correlated to markers of inflammation
CRP, IL-6, and IL1RA - Bad PP strongly associated with high levels of
IL-6 and IL-1RA ( p lt .001 and p0.004 resp) - Hand-grip strength correlate with CRP and IL-6
Cesari M
et al J Gerontol 200459A242248
16IMMUNE DEFICIENCIES ELDERLY PATIENTS WITH
COLORECTAL CANCER
- Immuno-reactivity impaired in under-nourished
- Preoperatively high age, low BMI, high levels
of IL-1 receptor antagonist (IL-1Ra) - Postoperatively Exaggerated IL-6 increase
increased postoperative loss of body weight
Miki
C et al Crit Care Med 200533177-80
17APR PRESSURE SORESCordeiro MBC et al Nutrition
2005 21901907
18APR CPR NUTRITIONAL CONTROLBengmark S
Nutrition 200117489-495
19APR Immunoparesis
- The height of acute phase response in the early
nervous phase is
strongly associated with the
depth of immunoparesis in the subsequent so
called immune phase.
20ACUTE PHASE RESPONSE
- Rise in cytokines and coagulation factors within
seconds - Rise in acute phase reactants with hours
- Disappearance of protective flora 6-8 hrs
- Overgrowth with PPMs after 10-12 hrs and
- TRANSLOCATION
21 NARROW THERAPEUTIC WINDOWif to prevent
- Reduced intestinal motility
- Deficient epithelial integrity
- Reduced preventive flora
- Overgrowth and increased virulence of PPMs
- Deranged metabolism
- Intestinal translocation
- REDUCED RESISTANCE TO MORBIDITY
22The BENGMARK Flocare feeding tube
23CYTOKINE REACTION IN LIVER TRANSPLANTATION
- Sixfold and more increase in TNF-alpha and IL-6
observed in patients - at the end of the unhepatic phase
- after 10 minutes of reperfusion
- at the end of the operation
who subsequently
developed infections
Sautner T et al Eur J
Surg 199516197-101
24THE INFLAMMATION BALANCE gt 2 mill different
molecules in absolute balance
homeostasis -
Cannon WB The autonomic nervous system an
interpretention Lancet 19301 1109
25DESTABILIZING FACTORS
- Mental and physical stress
- Excess of refined foods fats, sugars,
dysfunctioning peptides (AGEs ALEs),
hormones, chemicals (pharma)
-
increase prooxidant actions
- stimulate overexpression of NF-?B,
COX-2, LOX and iNOS
- destabilize the immune system
- reduce flora
-
decrease resistance to disease
26AGEs/ALEs AMPLIFIERS OF INFLAMMATIONBengmark S
JPEN 200731430-440
27AGEs/ALEs IN TISSUES
- Glycated proteins produce about 50 X more free
radicals than non-glycated proteins
AGEs and
ALEs accumulate in tissues (amyloid) make the
body autofluorencing
- induce inflammation infection
-
reduce antioxidant defense
- weaken immune system
-
impair DNA repair mechanisms
- induce tissue accumulation of
toxins accelerate the development of various
diseases
Thorpe
SR, Baynes JW Amino Acids 200325275-281
28AGEs INFLAMMATIONBohlender JM Am J Physiol
Renal Physiol 2005289F645-659
29DISEASES ASSOCIATED WITH ELEVATED AGEs/ALEs
- Aging
- Allergy
- Autoimmune diseases
- Alzheimers disease
- Parkinsons disease
- Amyotrophic lateral sclerosis
- Huntingtons disease
- Stroke
- Familial amyloidotic polyneuropathy
- Creutsfeldt-Jakob disease
- Downs syndrome
- Atherosclerosis
- Cardiovacular disease
- Cataract
- Glaucoma
- Macula degeneration
- Diabetes
- Hormone deficiencies
- Polycystic Ovary Syndrome
- Liver cirrhosis
- Chronic pulmonary disorders
- Rheumatoid diseases
- Fibromyalogia
- Ruptured Achilles tendon
- Osteoporosis
- Nephropathies
- Paradontosis
30SOURCES OF AGEsVlassera H Ann N Y Acad Sci
20051043452-460
31AGEs/ALEs IN FOODS
- HEATED DAIRY powdered milk (ice cream, baby
clinical nutrition formulas) cheese, espec when
heated rich in pizza, tacos, nachos, salads,
fast-food sandwiches and sauces brown cheeses - HEATED GRAIN PRODUCTS Bread esp. toasted bread,
bread crusts crisp breads - HEATED MEAT, POULTRY, FISH content increases as
one goes from boiling to oven frying
boiling (1000
kU/serving) lt roasting (4300 kU)lt broiling (5250
kU) lt deep frying (6700 kU) lt oven frying (9000
kU/serving).
Goldberg
T et al. J Am Diet Assoc 20041041287-1291 - Egg yolk powder, lecithin powder, coffee, espec
dark roasted, hard-cured teas, roasted and salted
peanuts, dark and sugar-rich alcoholic
beverages, broth, Chinese soy, balsamic vinegar,
Cola drinks etc
32SMOKING WITH THE STOMACH
- COPD doubled in the last 30 years
- Cured meats (bacon, sausage, luncheon meats, and
cured hams) induce inflammation - FEV1 when eating cured meats
- 3 to 4 times/mo 11.5 ml
- 5 to 13 times/mo 42.0 ml
- 14 or more times/mo 110 ml
- Jiang R et al Am J Respir Crit Care Med
2007175798804
33COPD ANTIOXIDANT INTAKETabak C et al Am J
Respir Crit Care Med 2001 1646164
- Study of 13,651 adults from Amsterdam,
Doetinchem, and Maastricht - of which 16 reported COPD
- Intake of solid fruits esp. catechin (tea
apple is assoociated with an increase in - FEV1 of 130 ml reduction of four main COPD
symptoms chronic cough, phlegm, breathlessness
p lt 0.001 - Flavonol and flavone (vegetables)intake was
independently associated with chronic cough only.
34DIETARY ENERGY RESTRICTION ASTHMAJohnson JB
et al Free Radic Biol 200742665-674
35COLA C0NSUMPTION BONE DENSITYTucker K et al Am
J Clin Nutr 200684936-942
36DAIRY-INDUCED INFLAMMATION
- Dietary proteins of cows milk induce
inflammation - release inflammatory mediators
- increase intestinal permeability
- induce leakage of albumin/hyaluronan
Jalonen T J Allerg Clin Immunol
199188737, Isolauri E Gastroenterology
19931051643, Bengtsson U et al. J Clin Exp
Allerg 199626197, Allerg Clin Immunol
1997100216
37ESTROGENS IN MILK Malekinejad H et al J Agric
Food Chem 200654 9785-9791
- Dramatic increase in testicular, breast,
prostate, ovarian, and corpus uteri , and large
bowel cancers. - 60-80 of the intake of estrogens originate in
the Western world from milk and other dairy
foods. - The daily intake of total estrogens through milk
is 372 ng, which is dramatically more than
currently recognized. - The content is twice as high in 3.5 fat milk
- 0 in non-fat milk
38FREE ESTROGENS IN DAIRY pg/g E1
E2 - 17ß E3
- Whole milk 3.7 6.4 9.0 Skimmed milk
20.2 3.4 8.2 Whey
3.6 1.5 3.0 Cottage cheese 34.9 10.8
6.1 Butter 539.4 82.3 86.8 - Wolford ST, Argoudelis CJ J Dairy Science
1979621458-1463
39- AGEs IN VARIOUS MILK PRODUCTS
- Baptista J, Carvalho R
Food Res Int
200437739-747
40METABOLIC SYNDROME IN COWS
- Modern feeds are rich in starch carbohydrates
(corn, maize grains, barley, molasses and
dextrose) will induce, also in cows
Insulin resistance - Insulin-resistance observed in calves fed an
intensive milk- and lactose diet
Hostettler-Allen
RL et al J Anim Sci 199472160-173 -
41DIET AND BREAST CANCERCarroll KK Cancer Res
1975353374-3383
42AGE IN VEGETARIAN DIET
- Fluorescent AGE
Omnivorous (n19) 9.90.5
Vegans (n9) 10.80.7
Ovolacto-vegetarians
(n19) 13.10.8 - Chemical AGE (CML)
Omnivorous (n19) 427.115.0
Vegans (n9) 514.824.6
Ovolacto-vegetarians (n19) 525.729.5 - Sebekova K et al Eur J Nutr 200140275281
43DRUGS RESISTANCE TO DISEASE
- Chemicals incl. pharmaceutical drugs suppress
innate immune functions. - Antibiotics suppress
- Lymphocyte
proliferation
- Macrophage functions such as chemiluminescence
response, chemotactic motility,
bactericidal cytostatic ability
Roszkowski K et al. Zeitschr Bakteriol Hyg
1988270270-279 Pulverer G
et al. Zentralbl Bakteriol 1990272467-476
44STRESS-INDUCED INFECTIONS
- Potentially pathogenic microorganisms (PPMs)
change under stress their phenotype and become
life-threatening
pathogens Alverdy JC
et al. Crit Care Med. 200331598-607 - Luminal release of noradrenaline is a strong
inducer of virulence of luminal bacteria
Kinney KS Life Science 2000673075-3085 -
45DRUGS BACTERIAL GROWTH
- - Noradrenaline increases the growth of E coli
and production of Shiga-like toxins - - ß-endorphins increase the growth of
gram-positives such as Staph aureus - 6-hydroxy-dopamine increases the total number
of bacteria in cecum with 3-4 logs
Lyte M, Bailey MT J Surg Res 199770195-201
46ADRENALIN CLOSTRIDIAL GROWTHCooper EV Lancet
194624459-461
47PN INFECTION
- A significant increase in mortality (63 vs 26)
- in patients with burns, fed with
parenteral nutrition
- Herndon DN et al . J Burn Care Rehabil
198910309313
48EN INFECTION
- Significant increase in bacterial translocation
in mice fed Vivonex (53), Criticare (67), or
Ensure (60) vs chow-fed (0) (p lt .05) - All three diets induced loss of jejunal and ileal
mucosal protein content, Intestinal microbial
overgrowth translocation - Haskel Y et al Crit Care Med 199422108-113
49ENTERAL NUTRITION INFLAMMATION
- Compared standard (Nutrison) a
immunomodulatory (Stresson) nutrition
in malnourished patients after pancreaticoduodenec
tomy. - Standard nutrition lead to significant elevations
of PRO-INFLAMMATORY cytokines - TNF-alpha day 3 (P0.006), day 7 (Plt0.001)
- IL-1beta day 7 (Plt0.001) day 14 (P0.022)
- Immunomodulatory nutrition lead to significant
elevations in ANTI-INFLAMMATORY cytokines - IL-8 day 1 (P0.011) days 3, 7, 10, 14
(Plt0.001), IL-10 days 3 10 (Plt0.001)
IL-1ra/s day 7 (Plt0.001), IL-6 day 10
(P0.017) - Slotwinski R et al. JOP. J Pancreas 2007
8759-769
50IMMUNONUTRITION IN SURGERY
- 1 lit/d Impact to elective major abd. surgery
patients - 5 days preop 7 days postop
- only postop 7 days
- The length of IMU/ICU stay , hosp stay
infect rate - PREPOSTOP 1.9 1.3 days 19.7 2.3 days
2/14 (14) - ONLY POSTOP 5.9 0.8 days 29.1 3.6 days
10/15 (67) - TNF-alpha (postop days 1 and 3) CRP (postop day
7) were significantly lower in the
preoppostop treated (p lt .01) - Giger U et al Ann Surg Oncol 2007142798-2806
51TAMING INFLAMMATION
- Alpha7 nicotinic acetylcholine receptor
antagonist deJonge WL, Ulloa L Br J Pharmacol.
2007 Aug151(7)915-929 (Amsterdam) - Enteral high-fat nutrition/release of
cholecystokinin Luyer M et al Crit Care Med.
2007352003-2004 (Maastricht) - Omega-3 Calder PC Proc Nutr Soc. 200665264-277
- Polyphenol antioxidants
Bengmark S JPEN J Parenter Enteral
Nutr. 20063045-51 - Plant fibres Xu D et al. JPEN 19982237-41
- Pre-, pro- synbiotics Bengmark S Anaesthesiology
Clinics of North America 200624299-323 -
52MULTIFIBRE IN ACUTE PANCREATITIS
- 30 severe acute pancreatitis patients received EN
with or without 24 g/d multifibre - Median duration with multifibre
- of EN was 8 4 (6-12) vs 10 4 (6-13) days
- to APACHE II normalization (lt 8) was
4 2 vs 6.5 3 days (P lt 0.05) - To CRP normalization
was 7 2 vs 10 3 days (P lt
0.05) - Karakan T et al World J Gastroenterol 2007
132733-2737
53A SHIELD AGAINST ACUTE AND CHRONIC DISEASE
Bengmark S JPEN J Parenter Enteral Nutr.
20063045-51
54TURMERIC - Curcumin
55CURCUMIN-REDUCED SEPSIS
- Curcumin pretreatment for 3 d before induction of
sepsis by cecal ligation and puncture - Prevents cellular alterations in macrophages
- Decreases expression of TNF-a,
- - Down-regulates PPAR-? in organs (liver)
- - Reduces tissue injury and mortality
- Siddiqui AM et al Crit Care Med 2006 341874-1882
- Curcumin attenuates endotoxin-induced
coagulopathy prevents disseminated
intravascular coagulation (DIC) - Chen HW et al J Endotoxin Res 20071315-23
56GUT FLORA IN AGING
Woodmansey EJ J Appl Microbiol 20071021178-1186
57THE IMMUNE SYSTEMBrandtzaeg, P et al
Gastroenterlogy 1989971562-1584
58ROLE OF FLORA/PROBIOTICS
- Control GI motility
- Reduce/eliminate potentially pathogenic micro-
organisms/PPMs - Reduce/eliminate the content of various
toxins, mutagens, carcinogens etc - Promote apoptosis
- Release and synthesizes numerous nutrient
antioxidants, growth-, coagulation and other
factors - Modulate the innate and adaptive immune
defence mechanisms
59AGING AND FLORA
- Blood samples and colonic biopsies from elderly
subjects (90-99 years) show significantly
down-regulated transcript levels of receptors
such as
- Toll-like receptors (TLRs) - - Nucleotide-binding
Oligomerization domain-like
receptors (NLRs) - Which may contribute to the lack of effective
recognition of invading pathogens or the
commensal flora. - Rosenstiel P et al Genes Immun. 2008 E-pub Jan 24
60BIOECOLOGICAL CONTROLBengmark S Anesthesiol
Clin N Amer 200624 299-323
61LACTOBACILLUS CONSUMPTION
- by the elderly improves specific immune
functions - Increases natural killer cell activity
- Takeda K, Okumura K. J Nutr 2007 137791S793S
- Increases phagocytic activity of PBMCs
Gill HS et al. Am
J Clin Nutr 2001 74833839. - Reduces the incidence of winter infections
- Turchet P, et al. J Nutr Health Aging
200377577 - Decreases the level by macrophages of TNFa
Matsumoto M, Benno Y. Biosci Biotechnol Biochem
2006 7012871292
62 REDUCED INFECTION RATE
- Ex. pancreatdoudenectomy Probiotic treatment
(lactic acid bacteria) from 53 gt 23 (P
0.02)Nomura T et al Hepatogastroenterol
200754661-663 synbiotic treatment (lactic
acid bacteria fibres)from 40 gt 12.5 (P
0.05) Rayes N et al Ann Surg 200724636-41
63SYNBIOTIC 2000 Medipharm AB, Kågeröd, Sweden
Des Moines, USA
- 1010 of Pediococcus pentosaceus 5-333
- 1010 of Leuconostoc mesenteroides 32-771
- 1010 of Lactobacillus paracasei sbsp. paracasei
- 1010 of Lactobacillus plantarum 2362
- 2.5 g of betaglucan
- 2.5 g of inulin
- 2.5 g of pectin
- 2.5 g of resistant starch
64LAB IN SYNBIOTIC 2000
- Induce several bioactive proteins five
cross-react with stress proteins - all - Transcribe NF-?B to the largest extent L
plantarum and L paracasei. - Produce pro-inflammatory cytokines (IL-1?, IL-8)
and anti-inflammatory (IL-10), to a large extent
by L plantarum, and less by Leuconostoc
mesenteroides.
Ljungh Å, Microb Ecol Health Dis 20023,
Suppl 44 Kruszewska D et al Microecol. Ther.
20022937
65LAB IN SYNBIOTIC 2000 cont
- Produce Antioxidants, espec.
Lb plantarum
Pediococcus
pentosaceus
Ljungh Å, Microb Ecol
Health Dis 20023, Suppl 44
Kruszewska D et al Microecol. Ther. 20022937 - Induce Heat Shock proteins espec. Leuconostoc
mesenteroides and
Lb paracasei subsp paracasei
Eleine Petrof, personal communication - Induce Beta-defensins espec. Pediococcus
pentosaceus and
Lb paracasei subsp paracasei
Wehkamp J
et al Infect Immun. 2004725750-5758
66PROBIOTICS IN CLP-INDUCED LUNG INJURY
- Lung injury induced by ceacal ligation and
puncture (CLP), two studies
1. Pretreatment with Synbiotic 2000 during 3 days
before CLP
Tok D et al J Trauma 200762880-885
2. Subcutaneous injection of live
Lactic acid bacteria in Synbiotic 2000
Ilkgul O
et al. Br J Int Care 20051552-57
67MYEOLOPEROXIDASE MPO Tok D et al J Trauma
200762880-885 U/g
- Synbiotic 2000 25.622.19
- Only LAB 26.752.61
- Only the fibres 56.591.73
- Placebo 145.537.53
plt 0.05
68MALONALDEHYDE MDA Tok D et al J Trauma
200762880-885 nmol/mg
- Synbiotic 2000 0.221,31
- Only LAB 0.283,55
- Only the fibres 0.485,32
- Placebo 0.672,94
plt 0.05
69NITRIC OXIDE Tok D et al J Trauma
200762880-885 micromol/g
- Synbiotic 2000 17.162,03
- Only LAB 8.912,24
- Only the fibres 47.713,20
- Placebo 66.225,92 plt
0.05
70NEUTROPHILS IN LUNG TISSUE Tok D et al J Trauma
200762880-885
- Synbiotic 2000 9.000.44
- Only LAB 8.400.42
- Only the fibres 31.200.98
- Placebo 51.100.70
- plt 0.05
71SYNBIOTIC 2000 IN LUNG INJURY Ilkgul O et al Br
J Int Care. 20051552-57
- Placebo Only fibres
Synbiotic 2000
72SYNBIOTIC 2000 IN CHRONIC LIVER DISEASE
- One month supply of Synbiotic 2000 reduces
- Mucosal pH
- PPM flora E. coli (plt0.001) Staphylococcus
(plt0.01) and Fusobacterium (plt0.05), - Endotoxin, ammonia/s, ALT/s, bilirubin/s
- Increases
albumin/s and prothrombin - Improves Child classification
degree of encephalopathy/psychomet
ric test in half of the patients
Qing-Liu et al. Hepatology 2004 391441-1449
73LIVER FUNCTION CHANGESRiordan SM et al Microb
Ecol Health Dis 2007197-16 Serum Bilirubin
(umol/L) Serum Albumin
(g/L)P0.002
P0.003
74Indocyanine Green Retention at 15 mins Riordan SM
et al Microb Ecol Health Dis 2007197-16
Synbiotic 2000 (p0.003) Control
(p0.37)
75SYNBIOTIC 2000 IN LIVER TRANSPLANTATION
- 50 to 85 of transplant patients develop
nosocomial infections within 30 days. - Synbiotic 2000 or Only fibres daily
from the day before
surgery
during 14 postop. days - 30 day-infection rate
- Synbiotic 2000 1/33 - 3
- Only fibres 17/33 - 51
- Rayes N et al. Am J Transplant 20055125-131
76SYNBIOTIC 2000 IN LIVER TRANSPLANTATION
- Isolated bacteria Synbiotic Fibres only
- Enterococcus faecalis 1
11 - Escherichia coli 0 3
- Enterobacter cloacae 0
2 - Pseudomonas aeruginosa 0
2 - Staphylococcus aureus 0 1
-
(total 1) (total 18)
Rayes N et
al. Am J Transplant 20055125-131 -
77SYN. 2000 IN ABD. CANCER
- The incidences of postoperative bacterial
infections were
Parenteral Nutrition 47 ,
EN fibres
20
EN Synbiotic 2000 7 - Significant improvements in prealbumin,
C-reactive protein, serum cholesterol, serum
endotoxin, white cell blood count, and IgA
Han
Chunmao et al. In press
78SYNBIOTICS IN SEVERE ACUTE PANCREATITIS 1 Oláh A
el al. Br. J. Surg 891103-1107
Trial in 45 patients, heatkilled (A) or live (B)
Lactobacillus plantarum 299 and 10 g oat fibre
during days.
Pancreatic sepsis (inf necroses/abscesses) A.
7/23 patients (30 ) B. 1/22 patients (4.5 )
p0.023 Mean length of stay A. 21.4 days B.
13.7 days ns
No statistically significant differences in
number of chest infections (22), SIRS (611)
MOF (22).
The only infection in the synbiotic treated
group occured on the 15th day, e.g. 8 days after
conclusion of supply of LAB and fibre
79SYNBIOTICS IN ACUTE PANCREATITIS Oláh A et al
Hepato-gastroenterology 20075436-41
- Isolated Microorganisms SYNBIOTIC 2000
Fibres Only - Pseudomonas aeruginosa 1 4
Enterococcus faecalis
1 2 - Enterobacter spp 1 1
- Streptococcus spp 2 -
- Staphylococcus aureus 1 1
- Enterococcus faecium 1 -
- Candida spp - 2
- Staphylococcus haemolyticus - 1
- Serratia spp - 2
- Klebsiella spp - 1
- Escherichia coli - 1
- Stenotrophomonas maltophilia - 1
- Citrobacter freundii -
1 -
(Total 7) (Total 17)
80SYNBIOTICS IN ACUTE PANCREATITIS 2Oláh A et al
Hepato-gastroenterology 20075436-41
- Synbiotic 2000 Fibres Only
- Total number of infections 9/33 ( 27 )
15/29 ( 52 ) - Pancreatic abscesses 2
2
Infected necrosis 2 6 - Chest infections 2
4 - Urinary infections 3 3
- SIRS 3 5
- MOF 5 9
SIRS MOF 8
14 plt0.05 - Late (gt48h) MOF 1 5
- Complications 9/33
15/29 plt0.05 - Surgical drainage 4/33 ( 12 )
7/29 ( 24 ) - Mean hospital stay 14.9 6.5
19.79.3 - Dead 2/33 ( 6 ) 6/29
( 18 )
81SYN. 2000 IN TRAUMA PATIENTS Spindler-Vesel A et
al. JPEN 200731119-126
- Number of chest infections
- Synbiotic 2000 1/14 7
- Only fibres 11/28 39
- Nutricomp peptide
10/21 48 - Glutamine 12/37
32 - Total number of infections
- Synbiotic 2000 2/14
14 - Only fibres 16/28
57 - Nutricomp peptide 11/21
52 - Glutamine 19/37
51 Both
glutamine and Synbiotic 2000
down-regulated Il-6
but not Il-8 and TNF.
82SYNBIOTIC 2000 IN SEVERE TRAUMA Kotzampassi K
et al. World J Surgery 2006301848-1855
- 102 patients with multiple trauma treated 5 days
with either Synbiotic 2000 Forte or placebo.
Synbiotic-treated patients exhibited
Reduced rate
of infections
(P 0.01)
Reduced rate of SIRS, severe sepsis
(P 0.02) mortality.
Reduced number
of days on mechanical ventilation (P 0.001).
Reduced ICU stay (P 0.01)
83SYNBIOTIC 2000 IN PANCREATECTOMY Rayes N et al.
Ann Surg 200724636-41
- Patients with infection
Synbiotics 2000 5/40 (12.5) Only
fibres 16/40 (40) plt 0.05 -
Synbiotic 2000 Only fibres
Wound
infections 4 6 Peritonitis
0 5 Pneumonia 0
4 Urinary 1 1
Sepsis 0 2
Cholangitis 0 1 Empyema 0 1
Total infections
5 20
84SYNBIOTIC 2000 IN PANCREATECTOMY Rayes N et al.
Ann Surg 200724636-41
- Synbiotic 2000 Only fibers
- Enterobacter cloacae 2
8 - Enterococcus faecalis/faecium 1 7
- Escherichia coli 0
7 - Klebsiella pneumoniae 2
2 - Proteus mirabilis 1
1 - Staphylococcus aureus 0
2 Total
6 27
85LAB ANTIBIOTIC-INDUCED DIARRHOEA
- 135 elderly hospital patients on antibiotics
consumed 100 g (97 ml) of a probiotic drink twice
a day during a course of antibiotics and for one
week after the course finished - 7/57 (12) of the probiotic group compared to
19/56 (34) in the placebo group developed
diarrhoea (P0.007) - No one in the probiotic group and 9/53 (17) in
the placebo group had diarrhoea caused by C
difficile (P0.001). - Hickson M et al BMJ 200733580
86 ALL PROBIOTICS ARE NOT PROBIOTICS - L lactis
- Desirable strains improve immune function by
increasing - the number of IgA-producing plasma cells
- /improving phagocytosis,
- the proportion of Th1 cells and NK cells
Ouwehand AC
et al Antonie Van Leeuwenhoek 200282279289 - The in vitro ability to induce production of
cytokines by 46 strains of L. lactis selected
from about 2600 LAB strains was studied. - Great inter-strain differences in induction of
IL-6 and IL-12 and TNF-a IL-6 varied between 0
and 138 (ng/ml), IL-12 varied between 0 and 37.3
(ng/ml) TNF-a varied between 0 and gt
20.0(ng/ml) - Suzuki Ch et al Int J Food Microbiol 2008 E-pub
87IMMUNE MODULATION L lactisSuzuki C et al Int J
Food Microbiol 2008
- Strains IL-6 (ng/ml) IL-12 (ng/ml) TNF-a
(ng/ml) - S63 138 37 20
- P79 100 23
10 - H-17 118 3
12 - H45 4 2
0.33 - O 62 4 2
0 - G50 10 2
16 - 1257 0.29 1
0.23 - ATCC19435 21 5
0 - O19 0 0
0 - O20 0 0
0 - LPS 170 8
4 -
88THE GREAT Ps
- Plantarum
- Paracasei
- Pediococcus pentosaceus
89Lb paracasei the master?
- the strongest
inducer of Th1 repressor of Th2 cytokines
when more than 100
strains are compared
Fujuwara D et al.
Allergy Immunol 2004135205-215
90Lb paracasei
- Induces cellular immunity
- Stimulates production of suppressive cytokines
TGFß and Il-10 suppresses CD4 T-cells - Suppresses in vivo and in vitro Th2 activity
v. der Weid et al Clin Lab Immunol
20018695-701 Ibnon-Zekri et al Infect Immun
200371428-436 - Suppresses splenocyte proliferation
Nagler-Anderson Crit Rev Immun
200020103-120 - Decreases antigen-specific IgE and IgG1
Prioult et al Clin Diagn Immunol 200310787-792
91EFFECTS OF LAB ON PERMEABILITY PAIN
- Compared in animals effects of three probiotic
strains Bifidobacterium lactis NCC362,
Lactobacillus johnsonii NCC533, and Lactobacillus
paracasei NCC2461 on
stress-induced changes in gut permeability on
sensitivity to colorectal distension (CRD) - Only Lb paracasei reduced significantly visceral
pain restored normal gut permeability. - Only Lb paracasei prevented visceral
hyperalgesia. - Eutamene H et al. J Nutr. 20071371901-1907
92LAB POST-INFECTIVE GUT DYSFUNCTION
- Rats received either Lactobacillus paracasei,
Lactobacillus johnsonii, Bifidobacterium longum,
or Bifidobacterium lactis during days 10 to 21
after Trichinella spiralis - induced infection. - Lb paracasei but NOT the other LAB
- - attenuated muscle hypercontractility
- - reduced the infection-associated
Th- 2 response
muscle levels of TGF-ß,
COX-2 and PGE2 - Verdú EF et al Gastroenterology 2004127826-837
93CONTROL OF PATHOGENS
- The ability of 50 different LAB to control 23
different pathogenic Clostridium difficile
27
were totally ineffective
18 antagonistic to some
5 effective against
all
2 strains - Lb paracasei subsp paracasei
3 strains - Lb plantarum
Naaber P et al.
Med Microbiol 200453551-554.
94LAB IN HEALTHY ELDERLY
- Twenty-four enterally fed gt 70 years
in-patients were treated with Lactobacillus
johnsonii La1 (LC1). - The percentage of days with infections during the
period before treatment was 15.4 17.3 - It decreased to 5.7 8.1 during the
intervention period (P 0.047) - Fukushima Y et al Br J Nutr 200798969-977
95Increasing evidence suggests
- Regular exercise
- Eating right
- Non-smoking
- Moderate alcohol intake
- Spiritual harmony/control of
stress
are
fundamental to good health and well-being
96EASE INFLAMMATION
- E ELIMINATE/MINIMIZE intake of proinflammatory
drugs nutrientsA ADD physical exercise
stress control to the extent possibleS
SUPPLEMENT anti-inflammatory nutrients
omega-3, various B D vitamins, zinc E
EAT/FEED non-processed fruit and vegetable juices.
97 THE DILEMMA!The sickest patient the
critically ill often elderly patient - Is in
constant mental physical stress- Cannot
exercise- Receives the worst food
98FUTURE NUTRITION OF THE ICU PATIENT ? Fresh
fruit and vegetable juices? Gaspacho?
99Our goal should be to provide the pleasure and
benefit of eating also to the very sick
s.bengmark_at_ucl.ac.uk
100THANK YOU!s.bengmark_at_ucl.ac.uk