Early metabolic support for critically ill trauma patients: A prospective randomized controlled trial. Issue 2 (2nd February 2022)

• Record Type: Journal Article
• Authors: Stolarski, Allan E.; Young, Lorraine; Weinberg, Janice; Kim, Jiyoun; Lusczek, Elizabeth; Remick, Daniel G.; Bistrian, Bruce; Burke, Peter
• Is Part Of: Journal of trauma and acute care surgery. Volume 92:Issue 2(2022)
• Page Start: 255
• Page End: 265
• Publication Date: 2022-02-02
• Subjects: Trauma -- nutrition -- inflammation -- cytokines -- amino acid; Surgical intensive care -- Periodicals; Surgical emergencies -- Periodicals; Wounds and injuries -- Surgery -- Periodicals; 617.026
• DOI: 10.1097/TA.0000000000003453
• Languages: English
• ISSNs: 2163-0755

Abstract

Abstract : Nutritional needs of critically ill trauma patients are rarely met in the 1st week s/p trauma. A pilot RCT by @Allan_Stolarski et al finds that early metabolic support (parenteral amino acids) alters the metabolism and may decrease inflammation in the 1st week after trauma. Supplemental digital content is available in the text. Abstract : BACKGROUND: There is a lack of consensus regarding the optimal nutritional support for trauma patients. We hypothesize that early postinjury metabolic support focusing on adequate protein would modify the metabolic signature and alter the inflammatory environment for critically ill trauma patients. METHODS: We conducted a prospective randomized controlled pilot trial for adult patients admitted to the surgical intensive care unit following traumatic injury. Patients were randomized to receive early metabolic support (EMS) (peripheral amino acid infusions) or standard of care (enteral nutrition as soon as feasible). Routine laboratory assessments, nitrogen balance, cytokines, and metabolomic analyses were assessed at baseline and day 5 after intervention. RESULTS: A total of 42 trauma patients were randomized into well-balanced groups with similar age (32 years), Injury Severity Score (25), and body mass index (27.4 kg/m 2 ). Early metabolic support provided significantly more protein (1.43 g/kg vs. 0.35 g/kg; p < 0.0001) and more calories (12.6 kcal/kg vs. 7.5 g/kg; p = 0.0012) over the first 5 days as compared with the standard of care. Early metabolic support modified protein catabolism and synthesis as demonstrated by a larger median negative nitrogen balance (−16.3 g vs. −5.3 g; p = 0.03) and a unique metabolomic profile at day 5. The biochemical profile of patients who received EMS was defined by greater declines in circulating levels of stress hormone precursors and increased levels of amino acids. The inflammatory response following EMS resulted in a greater decrease in interleukin-1B ( p = 0.02) and increase in soluble interleukin-6 receptor ( p = 0.01) between baseline and day 5 as compared with the standard of care. The EMS group had a decreased length of stay (15 vs. 22 days) and decreased surgical intensive care unit length of stay (8 vs. 9 days); however, this disappeared after adjustment for Injury Severity Score in this small population. CONCLUSIONS: Early metabolic support with amino acid is safe, modifies metabolism, and may downregulate the inflammatory state associated with significant trauma, warranting a larger trial to assess for improved outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II. Abstract :