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BACKGROUND: Functional electrical stimulation-assisted cycle ergometry (FESCE) can deliver active exercise to critically ill patients, including those who are sedated. Aerobic exercise is known to stimulate skeletal muscle glucose uptake. We asked whether FESCE can reduce intravenous insulin requirements and improve insulin sensitivity in intensive care unit (ICU) patients. METHOD: We performed an a priori-planned secondary analysis of data from an outcome-based randomized controlled trial (NCT02864745) of FESCE-based early-mobility program vs standard of care in mechanically ventilated patients. We analyzed glucose profile, glucose intake, and insulin requirements during ICU stay in all enrolled patients. In a nested subgroup, we performed hyperinsulinemic (120 mIU/min/m2 ) euglycemic clamps at days 0, 7, and 180 (n = 30, 23, and 11, respectively). RESULTS: We randomized 150 patients 1:1 to receive intervention or standard of care. Seventeen (23%) patients in each study arm had a history of diabetes. During ICU stay, patients received 137 ± 65 and 137 ± 88 g/day carbohydrate (P = .97), and 31 vs 35 (P = .62) of them required insulin infusion to maintain blood glucose 8.61 ± 2.82 vs 8.73 ± 2.67 mM (P = .75, n = 11,254). In those treated with insulin, median daily dose was 53 IU (interquartile range [IQR], 25-95) vs 62 IU (IQR, 26-96) in the intervention and control arm, respectively (P = .44). In the subgroup of patients undergoing hyperglycemic clamps, insulin sensitivities improved similarly and significantly from acute and protracted critical illness to 6 months after discharge. CONCLUSION: The FESCE-based early-mobility program does not significantly reduce insulin requirements in critically ill patients on mechanical ventilation.

Abstrakt

Effects of exercise on patient-centred outcomes in critically ill patients: systematic review and metaanalysis of randomised controlled trials

Anesteziologie a intenzivní medicína. 2019 ; 30 (5) : 204.

ISSN 1214-2158
Medvik
Zdroj

Publikační typ
abstrakt z konference MeSH

Článek

Svalová slabost kriticky nemocných
[Intensive care unit-acquired weakness]

Anesteziologie a intenzivní medicína. 2011 ; 22 (3) : 163-168.

Medvik
Zdroj

Nově vzniklá svalová slabost kriticky nemocných (ICUAW) je častou komplikací intenzivní péče s dalekosáhlým dopadem, především na její dlouhodobý výsledek. ICUAW je asociována se syndromem systémové zánětlivé odpovědi (SIRS) a lze na ni nahlížet jako na projev multiorgánové dysfunkce na úrovni periferního nervu a svalu. Na úrovni periferního nervu dochází k hyperpolarizaci membrány a poruše vedení vzruchu díky snížení počtu a změně vlastností Na+ kanálů. Ve svalových vláknech je porušena fluk - tuace intracelulární koncentrace Ca2+ v průběhu cyklu kontrakce-relaxace. Snižuje se též obsah kontraktilních bílkovin (proteolýza), jader (apoptóza) i mitochondrií, které jsou funkčně defektní (bioenergetické selhání). Postižení svalu u kriticky nemocného tedy zahrnuje jak funkční defekt (myopatii), tak úbytek tkáně (sarkopenii). Klinická diagnostika ICUAW je v podmínkách JIP/ARO obtížná a často opožděná, přesné určení podílu postižení nervové a svalové tkáně na svalové slabosti má spíše akademický význam, neboť specifickou terapii v současnosti neznáme. Prevence a terapie je individualizovaná a spočívá v minimalizaci vyvolávajících faktorů, adekvátní nutrici (prevence sarkopenie) a co nejčasnější mobilizaci kriticky nemocného.

Intensive Care Unit-Acquired Weakness (ICUAW) is a common complication of intensive care that places significant impact on the long-term outcome. ICUAW is associated with systemic inflammatory response syndrome (SIRS) and is now considered an aspect of the multiple-organ failure syndrome at the level of peri - pheral nerves and muscles. The membrane of the peripheral nerve is hyperpolarized and is inexcitable at least in part due to the changes of both the number and features of the Na+ channels. Within the muscles, the intracellular Ca2+ fluctuation pattern flattens during the cycle of contraction-relaxation. There is also a decrease in the contractile protein content, and in the reduction of the number of both the nuclei and mitochondria. Thus, the muscle involvement in ICUAW includes both functional changes (myopathy) and a net loss of muscle tissue (sarcopenia). The diagnosis of ICUAW is difficult and often delayed. Direct assessment of the extent to which the muscles and nerves contribute to weakness is often not worthy, as no specific therapy is yet available. The prevention and management of ICUAW now consist of avoiding risk factors, providing adequate nutrition and encouraging the culture of early mobilization of ICU patients.

Klíčová slova
SIRS, polyneuromyopatie,
MeSH
kritický stav terapie MeSH
lidé MeSH
neuromuskulární nemoci etiologie prevence a kontrola terapie MeSH
péče o pacienty v kritickém stavu metody MeSH
sarkopenie patofyziologie prevence a kontrola MeSH
svalová slabost diagnóza patofyziologie prevence a kontrola MeSH
svaly patofyziologie patologie MeSH
syndrom systémové zánětlivé reakce komplikace MeSH
Check Tag
lidé MeSH
Publikační typ
přehledy MeSH

Článek

Tolerance akcelerované pooperační rehabilitace po střevních resekčních výkonech
[Tolerance of accelerated postoperative rehabilitation following intestinal resections]

Rozhledy v chirurgii. 2009 ; 88 (4) : 178-184.

ISSN 0035-9351
Medvik
Zdroj

Úvod: Moderní postupy v perioperační péči vycházející z principů medicíny založené na důkazech zlepšují pooperační výsledky. Jejich osvojení však není běžnou klinickou praxí na většině chirurgických pracovišť. Cíl: Cílem naší studie bylo vypracování protokolu a jeho zavedení do praxe. Předmětem sdělení je tolerance protokolu v našich podmínkách. Pacienti a metoda: Do prospektivní randomizované studie byli zařazeni nemocní operovaní (otevřená střevní resekce) na chirurgické klinice 4/2005–12/2007 a randomizováni do fast track skupiny (n = 53) a non-fast track skupiny (n = 52). Ve fast track skupině (FTS) bylo postupováno podle protokolu akcelerované rehabilitace, v non-fast track skupině (non-FTS) tradičním způsobem. Výsledky byly statisticky zhodnoceny. Dva nemocní z FTS byli vyřazeni z hodnocení pro časné porušení protokolu personálem. Protokol i informovaný souhlas pacienta byly schváleny etickou komisí nemocnice. Výsledky: Skupiny se nelišily věkem, diagnózou a délkou operace. Analgezie byla významně lépe kontrolovaná ve FTS, podobně tolerance perorálního příjmu byla v této skupině vyšší (operační den – průměrně 634 ml, proti 304 ml). Návrat střevní pasáže byl ve sledované skupině rychlejší (průměrně 2,1 proti 3,9 dnů). Frekvence pooperačních komplikací byla nižší, délka hospitalizace byla kratší (medián 7,0, proti 9,0 dne, p < 0,001). Závěr: Vypracovaný protokol fast track pooperační rehabilitace bylo možné v rámci studie zavést do klinické praxe. Tolerance nemocnými byla velmi dobrá. Uplatnění postupů akcelerované rehabilitace je v našich podmínkách možné, znamená to však překonat horší toleranci ošetřujícího personálu.

Introduction: Modern procedures in peri-operative care arising from evidence-based medicine improve postoperative results. Their acceptance is however not a common clinical practice at most surgical centers. Aim: The aim of our study was to design a protocol and introduce it into the praxis. The subject of announcement is tolerance of protocol in our conditions. Patients and method: Prospective randomized study included patients who were operated on (open bowel resection) at Department of Surgery in period 4/2005–12/2007. They were randomized in fast track group (n = 53) and non-fast track group (n = 52). Protocol with accelerated recovery was used in the fast track group (FTG) and we used traditional approach in the not-fast track (non-FTG). Results were statistically evaluated, 2 patients (FTG) were excluded from analysis for protocol failure (protocol was non kept by anesthesiologist in 1 patient and by the nurse in the second patient). Protocol and informed consent form was approved by the Hospital Ethics Committee. Results: Both groups did not differ in age, diagnosis and length of surgery. Analgesia was controlled significantly better in FTG; similarly oral intake tolerance was higher in this group (day of surgery – mean value 634 ml versus 304 ml). Restoration of bowel functions was also faster in interventional group (mean time 2.1 versus 3.9 days). Frequency of postoperative complications was lower and hospital stay was shorter (median 7.0 versus 9.0 days, p < 0.001). Conclusion: Designed fast track protocol of postoperative recovery could be introduced in clinical praxis in terms of study. Patients’ tolerance was very good. Application of accelerated recovery procedures is possible in our conditions but it means primarily to overcome worse tolerance of attending personnel.

Článek

Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456)

Clinical nutrition. 2009 ; 28 (6) : 618-624.

Clin Nutr
ISSN 0261-5614
Medvik
Zdroj

BACKGROUND: Studies have shown the value of using fast-track postoperative recovery. Standard procedures (non-fast-track strategies) remain in common use for perioperative care. Few prospective reports exist on the outcome of fast-tracking in Central Europe. The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection. PATIENTS AND METHODS: One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were randomly selected for the fast-track group (FT) and non-fast-track group (non-FT). A designed protocol was used in the FT group with the emphasis on an interdisciplinary approach. The control group (non-FT) was treated by standard established procedures. Postoperative pain, rehabilitation, gastrointestinal functions, postoperative complications, and post-op length of stay were recorded. RESULTS: Of 105 patients, 103 were statistically analyzed. Patients in the FT group (n=51) and non-FT group (n=52) did not differ in age, surgical diagnosis, or procedure. The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions (bowel movement after 1.3 days vs. 3.1, p<0.001). Food tolerance was significantly better in the FT group and rehabilitation was also faster. Hospital stay was shorter in the FT group - median seven days (95% CI 7.0-7.7) versus ten days (95% CI 9.5-11.3) in non-FT (p<0.001). Postoperative complications within 30 postoperative days were also significantly lower in the FT group (21.6 vs. 48.1%, p=0.003). There were no deaths and no patients were readmitted within 30 days. CONCLUSIONS: Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay. We conclude that the FT strategy is safe and effective in improving postoperative outcomes.