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Dickerson et al
baseline (p < 0.01). Early biomarker changes may predict
later changes in DB concentrations, as demonstrated by positive correlations between differences in stigmasterol (r =
0.68, p = 0.03) and IL-8 (r = 0.75, p < 0.01) concentrations.
Cholestasis resolution may also be predicted by low early
IL-8 concentrations or those that experience larger changes
in docosahexaenoic acid and linoleic acid.
This study is limited by small sample size, observational
design, absence of a comparator group, lack of control for
confounding variables, and a limited number of time points
evaluated. Data may also have been confounded by a significantly higher EN intake at the end of the study. Nevertheless,
the study provides insight into the impact that polyunsaturated fatty acids and the phytosterol content of ILE has on
cytokine and bile acid levels and its potential contribution to
development and treatment of IFALD. Further well-designed
and larger trials are necessary to more conclusively evaluate
these associations and potential hepatoprotective effects of
FO.

This study suggests sarcopenic patients may benefit from
early nutrition intervention, but it is not without limitations,
including its retrospective nature, single-center design, and
relatively small sample size. The study definition of sarcopenia uses the assessment of muscle mass but not function
and therefore may not accurately capture the sarcopenic
population.29 Finally, all patients in the study received calorie and protein amounts well below recommended targets
(14.4 kcal/kg/d in EEN groups versus 9.7 kcal/kg/d in those
who did not receive EEN, p < 0.001; 0.5 g/kg/d protein in
EEN group versus 0.3 g/kg/d protein in those who did not
receive EEN, p < 0.001), which may have impacted results.
Overall, these findings indicated EEN was associated with
lower mortality in sarcopenic critically ill patients. Further
investigation in larger and more diverse ICU populations is
warranted.

Koga et al8: Early enteral nutrition is associated with
reduced in-hospital mortality from sepsis in patients
with sarcopenia.

Historically, saline has been the fluid of choice for resuscitation but may be associated with adverse events such as
hyperchloremic metabolic acidosis and acute kidney
injury.31,32 The objective of this pragmatic, unblinded, clustered-randomized, multiple-crossover trial was to determine
the effect of intravenous (IV) fluid administration with balanced crystalloids versus saline on clinical outcomes in critically ill adults. The participating ICUs for this single-center
study were randomized to use balanced crystalloids (either
lactated Ringer's or Plasma-Lyte A) or 0.9% sodium chloride
in alternating months. There were no significant differences
in the baseline characteristics for the 7 942 patients in the
balanced crystalloids group and 7 860 patients in the saline
group. For the primary composite outcome of major adverse
kidney event within 30 days, which encompassed death, new
renal replacement therapy (RRT), or persistent renal dysfunction (final inpatient creatinine value ≥200% of the baseline value), 14.3% in the balanced crystalloid group versus
15.4% in the saline group (0 = 0.04) had an event; however,
there were no statistically significant differences in the components of the composite outcome. There were no significant
differences in in-hospital mortality, ICU-free days, ventilator-free days, or vasopressor-free days. In the balanced crystalloids group, there were more RRT-free days. The authors
concluded that IV administration of balanced crystalloids
compared to saline resulted in a better composite outcome of
death, new RRT, and persistent renal dysfunction in critically
ill patients.
The use of balanced crystalloids may prevent major
adverse kidney events within 30 days in critically ill patients,
but aspects of study design warrant cautious interpretation.
First of all, while use of the composite outcome is supported
by the National Institute of Diabetes and Digestive and
Kidney Diseases, it may have exaggerated the treatment
effect. The study included multiple types of ICU patients, but

EEN is recommended in critically ill patients but controversy exists regarding the specific populations that may
benefit most from its use. Sarcopenia, a condition describing loss of skeletal muscle mass and function, is thought to
be a contributing factor to poor outcomes in hospitalized
patients and has been associated with increased mortality in
septic patients.29,30 This single-center retrospective study
compared the effects of EEN in critically ill septic patients
with sarcopenia to those without sarcopenia. No formalized
protocol for nutrition therapy was used. Abdominal computed tomography performed within 24 hours of ICU admission was used to diagnose sarcopenia via the skeletal muscle
area (SMA) at the third lumbar vertebra. Sarcopenia was
defined as SMA <80% of the predicted value according to
body surface area (BSA). A total of 191 patients were studied, including 91 with sarcopenia (48%). Sarcopenic patients
had higher acute physiology and chronic health evaluation
II scores, were at greater nutritional risk as classified by the
modified NUTrition Risk in the Critically Ill (mNUTRIC)
scores and had lower body mass indexes (BMIs) than
patients without sarcopenia. The sarcopenic group was less
likely to receive EN than the nonsarcopenic group (38% vs
43%). Mortality was lower in sarcopenic patients who
received EEN than in those who did not receive EEN (9% vs
34%, p = 0.005), but no difference was found in patients
without sarcopenia. Logistic regression found that in sarcopenic patients, EEN was independently associated with
lower in-hospital mortality, odds ratio (OR) 0.18, (95% confidence interval [CI], 0.05-0.71, p = 0.014. However, EEN
did not significantly influence mortality in those without
sarcopenia.

Semler et al9: Balanced crystalloids versus saline in
critically ill adults.

Hospital Pharmacy - October 2019

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