Perioperative care for the older patient with malnutrition Stig Bengmark MD PhD University College, - PowerPoint PPT Presentation

1 / 100
About This Presentation
Title:

Perioperative care for the older patient with malnutrition Stig Bengmark MD PhD University College,

Description:

Perioperative care for the older patient with malnutrition Stig Bengmark MD PhD University College, – PowerPoint PPT presentation

Number of Views:114
Avg rating:3.0/5.0
Slides: 101
Provided by: sti90
Category:

less

Transcript and Presenter's Notes

Title: Perioperative care for the older patient with malnutrition Stig Bengmark MD PhD University College,


1
Perioperative 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!

2
AGING 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

3
AGING 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

4
AGING 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.

5
AGING ORGAN FUNCTION After Hertoghe T Ann NY
Acad Scien 20051017448-465
6
SINGLE 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

7
THE 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

8
THE 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

9
PROTEIN 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

10
PREDICTION 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

11
A MOTHER OF DISEASE
Bengmark S. J Clin Nutr
2004231256-1266
12
INFLAMMATION 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

13
KATRINA 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

14
SYSTEMIC 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

15
INFLAMMATION 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

16
IMMUNE 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

17
APR PRESSURE SORESCordeiro MBC et al Nutrition
2005 21901907
18
APR CPR NUTRITIONAL CONTROLBengmark S
Nutrition 200117489-495
19
APR 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.

20
ACUTE 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

22
The BENGMARK Flocare feeding tube
23
CYTOKINE 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

24
THE INFLAMMATION BALANCE gt 2 mill different
molecules in absolute balance
homeostasis -
Cannon WB The autonomic nervous system an
interpretention Lancet 19301 1109
25
DESTABILIZING 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

26
AGEs/ALEs AMPLIFIERS OF INFLAMMATIONBengmark S
JPEN 200731430-440
27
AGEs/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

28
AGEs INFLAMMATIONBohlender JM Am J Physiol
Renal Physiol 2005289F645-659
29
DISEASES 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

30
SOURCES OF AGEsVlassera H Ann N Y Acad Sci
20051043452-460
31
AGEs/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

32
SMOKING 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

33
COPD 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.

34
DIETARY ENERGY RESTRICTION ASTHMAJohnson JB
et al Free Radic Biol 200742665-674
35
COLA C0NSUMPTION BONE DENSITYTucker K et al Am
J Clin Nutr 200684936-942
36
DAIRY-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

37
ESTROGENS 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

38
FREE 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

40
METABOLIC 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

41
DIET AND BREAST CANCERCarroll KK Cancer Res
1975353374-3383
42
AGE 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

43
DRUGS 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

44
STRESS-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

45
DRUGS 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

46
ADRENALIN CLOSTRIDIAL GROWTHCooper EV Lancet
194624459-461
47
PN 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

48
EN 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

49
ENTERAL 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

50
IMMUNONUTRITION 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

51
TAMING 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

52
MULTIFIBRE 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

53
A SHIELD AGAINST ACUTE AND CHRONIC DISEASE
Bengmark S JPEN J Parenter Enteral Nutr.
20063045-51
54
TURMERIC - Curcumin
55
CURCUMIN-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

56
GUT FLORA IN AGING
Woodmansey EJ J Appl Microbiol 20071021178-1186

57
THE IMMUNE SYSTEMBrandtzaeg, P et al
Gastroenterlogy 1989971562-1584
58
ROLE 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

59
AGING 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

60
BIOECOLOGICAL CONTROLBengmark S Anesthesiol
Clin N Amer 200624 299-323
61
LACTOBACILLUS 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

63
SYNBIOTIC 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

64
LAB 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

65
LAB 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

66
PROBIOTICS 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

67
MYEOLOPEROXIDASE 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

68
MALONALDEHYDE 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

69
NITRIC 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

70
NEUTROPHILS 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

71
SYNBIOTIC 2000 IN LUNG INJURY Ilkgul O et al Br
J Int Care. 20051552-57
  • Placebo Only fibres
    Synbiotic 2000

72
SYNBIOTIC 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

73
LIVER FUNCTION CHANGESRiordan SM et al Microb
Ecol Health Dis 2007197-16 Serum Bilirubin
(umol/L) Serum Albumin
(g/L)P0.002
P0.003
74
Indocyanine Green Retention at 15 mins Riordan SM
et al Microb Ecol Health Dis 2007197-16
Synbiotic 2000 (p0.003) Control
(p0.37)
75
SYNBIOTIC 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

76
SYNBIOTIC 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

77
SYN. 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

78
SYNBIOTICS 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
79
SYNBIOTICS 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)

80
SYNBIOTICS 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 )

81
SYN. 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.

82
SYNBIOTIC 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)

83
SYNBIOTIC 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

84
SYNBIOTIC 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

85
LAB 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

87
IMMUNE 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

88
THE GREAT Ps
  • Plantarum
  • Paracasei
  • Pediococcus pentosaceus

89
Lb 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

90
Lb 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

91
EFFECTS 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

92
LAB 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

93
CONTROL 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.

94
LAB 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

95
Increasing evidence suggests
  • Regular exercise
  • Eating right
  • Non-smoking
  • Moderate alcohol intake
  • Spiritual harmony/control of
    stress
    are
    fundamental to good health and well-being

96
EASE 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

98
FUTURE NUTRITION OF THE ICU PATIENT ? Fresh
fruit and vegetable juices? Gaspacho?
99
Our goal should be to provide the pleasure and
benefit of eating also to the very sick
s.bengmark_at_ucl.ac.uk
100
THANK YOU!s.bengmark_at_ucl.ac.uk
Write a Comment
User Comments (0)
About PowerShow.com