Probiotics in ICU: UPDATED

It certainly got me thinking when several people messaged and commented to me regarding their hospitals not allowing probiotics on their ICU patients. I decided to take a little bit of time to see if this was an old habit that just doesn't die, you know, a resistance to change, or if it's something substantiated by data. 

At first I didn't find anything to substantiate the claims. Key words were "at first". Now I understand what they're talking about and I even more appreciate the fund of knowledge that this page brings to the medical community. 

The exact mechanism, whether translocation from the gut, contamination with a central line, or something else is unknown. What is known is that 1.1% (6 of 522) of the patients at this facility who received probiotics developed a bacteremia related to the probiotic agent. That's not a large number but at the same time a large number in my opinion. I'll stress again, my opinion, not medical advice. I do not want to cause harm to my ICU patients. For those wondering, these patients were not severely immunocompromised nor did they have bowel disintegrity. 

I will wait until more data comes out before I start implementing this in my practice. As always, I appreciate the insight that you all provide. 

A hat tip to the authors. 

-EJ

Yelin, I.; Flett, K.B.; Merakou, C.; Mehrotra, P.; Stam, J.; Snesrud, E.; Hinkle, M.; Lesho, E.; McGann, P.; McAdam, A.J.; et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat. Med. 2019, 25, 1728–1732.

Link to the Article

Yelin, I.; Flett, K.B.; Merakou, C.; Mehrotra, P.; Stam, J.; Snesrud, E.; Hinkle, M.; Lesho, E.; McGann, P.; McAdam, A.J.; et al. Genomic and epidemiological evidence of bacterial transmission from probiotic capsule to blood in ICU patients. Nat. Med. 2019, 25, 1728–1732.

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Probiotics in the ICU

ADDENDUM: I have found new data regarding probiotics leading to bacteremia that was published HERE. This changes my take on prior research. 

Here's something I'm fairly certain we (meaning your team and mine) do not do in our practice that perhaps we should give some more consideration to: providing probiotics for our patients.

There's much we don't know regarding the microbiome. It completely fascinates me. Immediately upon arrival to the ICU, damage is done to the microbiome in our intestines via stress, shock, antibiotics, etc. Bad bugs take over where the good bugs used to live. How do we get those good bugs to come back? Could providing good bugs (probiotics) help get our patients better faster?

The following slides are some of my preliminary slides for my "ICU Nutrition and Gut Health" lecture. I was a bit too excited to share to wait until they were complete.

The 2016 ASPEN guidelines state that they cannot make a recommendation regarding using them routinely. I'm curious as to whether the 2020 guidelines (coming out next month) will state the same. I have cited articles where probiotics improve antibiotic associated diarrhea, two meta-analyses where they show benefit for ventilator associated pneumonias, a meta-analysis where the show decreased overall infections, and how they help to reduce the development of C.diff.

Now, if one were to think that probiotics were a cure to everything, that person would be wrong. There will likely never be a one-treatment to cure all the ailments in critical care. But if we can keep adding tools to our tool belts as more data comes out, then we will better be able to care for our patients and improve outcomes.

A hat tip to all the authors.

-EJ

Link to Article

McClave SA, Taylor BE, Martindale RG, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition: Guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159–211

Link to Article

Hempel, S. et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA 307, 1959–1969 (2012).

Link to Article

Weng, H.; Li, J.G.; Mao, Z.; Feng, Y.; Wang, C.Y.; Ren, X.Q.; Zeng, X.T. Probiotics for preventing ventilator-associated pneumonia in mechanically ventilated patients: A meta-analysis with trial sequential analysis. Front. Pharmacol. 2017, 8, 717.

Link to Article

Manzanares, W., Lemieux, M., Langlois, P.L. et al. Probiotic and synbiotic therapy in critical illness: a systematic review and meta-analysis. Crit Care 20, 262 (2016).

Link to Article

Goldenberg JZ, Yap C, Lytvyn L, Lo CKF, Beardsley J, Mertz D, Johnston BC. Probiotics for the prevention of Clostridium difficile‐associated diarrhea in adults and children. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD006095.

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Nutrition in Critical Illness

I’m writing a lecture on Nutrition for the ICU patient population. It’s been quite tough to find substantial data because of the many nuances and the vast heterogeneity of the patient population. That being said, this review article came out a few days ago and it provides a guide of sorts to provide our patients with nutrition during their different phases in the ICU. My understanding is that the ASPEN group shall be meeting towards the end of March. I am looking forward to whatever guidance they can provide so I can better care for my patients.

Fortunately this article is free! A hat tip for the authors.

Lambell, K.J., Tatucu-Babet, O.A., Chapple, L. et al. Nutrition therapy in critical illness: a review of the literature for clinicians. Crit Care 24, 35 (2020).

Link to article

Link to FREE PDF

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Lactate Levels cannot be corrected by Giving More Oxygen

I have covered lactate quite thoroughly over the last couple weeks but I still receive comments and questions from followers talking about oxygen deficiency to the cell causing elevated lactate and lactic acidosis. They ask "why don't you just increase the O2 that you're providing to the patient to help the cells out"? This question is not out of line with traditional thinking behind lactic acidosis being the byproduct of "tissue hypoxia" which I hope at this point you understand is NOT the cause of elevated lactate levels in septic shock patients (see many other posts for further details).

This study published in JAMA in 1993. The three key findings of their work include:

1. Critical O2 delivery was identified and is considerably lower than previously estimated. Increasing O2 delivery to supra-normal levels in critically ill patients in the hope of increasing O2 consumption may be inappropriate.

2. Sepsis was not associated with an increased critical O2 delivery

3. The increased concentration of arterial lactate at baseline was not associated with global tissue hypoxia, suggesting that lactate may not be a specific marker of tissue hypoxia in critically ill patients.

Hope this helps! A hat tip to the authors!

- EJ



Link to Article

Ronco JJ, Fenwick JC, Tweeddale MG, et al. Identification of the Critical Oxygen Delivery for Anaerobic Metabolism in Critically III Septic and Nonseptic Humans. JAMA. 1993;270(14):1724–1730.

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Can We Use Something Other Than Lactate To Guide Resuscitation?

Nurses: you see those orders. q1, q2, q4h lactates to help guide resuscitation in septic shock. You have to drop what you're doing and draw labs. Hopefully, if the patient is sick enough to need the labs, they have a central line. Hold off of titrating drips, hold off on the ever important charting you are required to do, let's trend lactates which I have previously discussed the utility of (or lack of utility). Along the way we contribute to iatrogenic anemia, spend a bunch of lab money, etc.

What if there was another option? Well, the ANDROMEDA-SHOCK trial proves that you can intelligently resuscitate patients without checking lactate levels. What they did was randomize >400pts to either have their resuscitation guided by lactate or this nifty little trick called Capillary Refill Time.

One of my favorite parts of the trial wasn't even the CRT vs. lactate component but their algorithm to determine fluid responsiveness which is a major interest of mine. I am not a fan of arbitrarily giving a pt liter after liter of fluid to "clear lactate" or improve the blood pressure. That just does not work and my body of work has data to prove that. I digress. Sometimes you need to read the supplementary materials in these articles as their algorithm was hidden in there.

Standard of care by CMS (the body that pays the hospitals and therefore us in the US) has mandated checking lactates despite no good evidence that trending it does much. This study shows that checking CRT is AT LEAST as good as checking lactate levels. The mortality was not statistically significant (p=0.06) but I wonder what would've happened if they would've had an additional 200pts in the trial. The CRT group had 34.9% mortality vs 43.4% in the lactate group. The CRT group also had fewer organ failures (p=0.045). Other fun facts include the fact that the lactate group received more fluids in the first 8h (p=0.01) but not overall. I don't know what to make of this.

All in all, even with its limitations, I feel this is a solid study. I really like it. I do not use CRT in my practice but I may be asking for a microscope slide to keep in my pocket in the upcoming weeks.

A hat tip to the authors

Hernandez G, Ospina‐Tascon GA, Damiani LP, Estenssoro E, Dubin A, Hurtado J, et al. Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28‐day mortality among patients with septic shock: the ANDROMEDA‐SHOCK randomized clinical trial. JAMA. 2019;321(7):654–64.

- EJ




Link to FULL FREE ARTICLE

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How Does Lacate Turn Into Lactic Acid?

You have NO IDEA how much I banged my head against my desk looking for the answer to the question: how does lactate turn into lactic acid? Well, after many hours of searching for an answer, and you can think I'm a dummy for not find the answer sooner or knowing it like a useless fact off of the top of my head, I FOUND IT! It's honestly some information that's not readily available. Many articles play it off and don't mention specifics assuming that "it just happens". I am by no means a biochemist. I'm simply trying to understand all this. In my explanation, I purposefully will be oversimplifying things.

Here's how it works:
In the cytosol, pyruvate turns into lactate (rather than move towards acetyl-CoA) for a number of reasons, again that I'm not going to get into, via lactate dehydrogenase. That lactate (via shuttles) gets to the cytosol of the liver and kidneys where it eventually makes its way into the Cori/Lactic Acid Cycle. The Cori cycle eventually spits out glucose. So far so good, right? Glucose via glycolysis seems to be metabolized into lactate, ATP, and water. Said ATP gets hydrolyzed into ADP and inorganic phosphate which releases that very necessary proton (H+). When conditions get revved up, i.e. septic shock, and an excess of lactate is being produced, then the cell cannot handle the metabolism of lactate and guess what's also being overproduced? Said H+ which tags onto the lactate creating lactic acid.

The articles I've read tend to say that you start running into lactic acidosis territory when you have a lactate 5 with a concurrent acidosis (pH less than 7.35). 

Mad props to Amanda, my pharmacist teammate, for listening to me and helping me work through this while not making too much fun of me. 
<7 .35="" additional="" again.="" and="" any="" are....="" be="" better.="" biochemistry="" br="" can="" definitely="" did="" diving="" going="" help="" here="" i="" into="" knowledge="" me="" nbsp="" never="" of="" or="" others="" pointers="" provide="" think="" this="" to="" understand="" was="" we="" welcome="" you="">
Link to article (NOT FREE)

Fall P, Szerlip H. Lactic acidosis: from sour milk to septic shock. J Intensive Care Med 2005; 20: 255-71.

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Lactate in IVF Leads to Lactic Acidosis?

"Lactate in fluids, such as Ringer's lactate, causes a lactic acidosis". Ugh. How I cringe every time I hear or read that. You should take into account your patients organ failures since lactate is metabolized approximately 60% in the liver, 30% in the kidneys, and 10% elsewhere (including the heart, muscles, etc depending on your source).

There's no perfect trial to go ahead and prove this concept, but I have linked this study which FREE where they provided patients with a sodium lactate solution versus Hartmann's solution, aka Ringers Lactate. To provide some context, LR provides the patient with Sodium Lactate, 28mmol/L to be exact. The half-molar Sodium Lactate solution described in this article has 504mmol/L of Sodium Lactate. I struggled quite a bit to find that concentration but thankfully I found it in a Spanish (Spain) article.

I have attached the table to illustrate several points. First, if you notice the Sodium Lactate did not create an acidosis in any of the patient groups, on the contrary, they trended more so towards an alkalosis, even a statistically significant alkalosis in the case of the "lactate" group. Overall, there was no increase in lactate whatsoever in the LR group which means that there's no "lactic acidosis" created by LR. It does not make patients acidotic. If you have a functioning liver and kidneys, that lactate is metabolized into bicarbonate. Hope that all makes sense.

A hat tip to the authors.

-EJ

Link to Article

Link to FULL FREE PDF

Nalos, M., Leverve, X.M., Huang, S.J. et al. Half-molar sodium lactate infusion improves cardiac performance in acute heart failure: a pilot randomised controlled clinical trial. Crit Care 18, R48 (2014)

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Elevated Lactate Does Not Equal More Fluids

There is a law of diminishing returns when resuscitating patients with bolus after bolus of IV fluids.

Yes, lactate decreased with additional boluses by 1.3% per every 7.5mg/kg increase in fluids making the numbers look pretty, but does that mean we're treating the source of the lactate or are we just diluting it? This study shows that mortality actually increases as we keep providing more fluids.

I’m not saying that patients who are in septic shock do not need fluids. On the contrary, they need judicious use of IV fluids and 30cc/kg initial resuscitation is okay with me in the vast majority of patients. I had to read many articles to finally fall in line with that. Of course there are several patient populations where I’m against it. For example, severe pulmonary hypertension patients with right hearts living on a tight rope. I digress. But tagging along with my prior post discussing giving fluid boluses reflexively, this study shows that fluids don’t really “clear” lactate in the way we all hope and want them to. The correlation of having an elevated lactate to mortality is there. The correlation with more fluids making lactate decrease isn’t. The pathophysiology behind where lactate comes from explains why not. And as we all should know, fluids are not benign. The more fluids we give patients the higher the mortality per the 9000 that were assessed in this study.
A 🎩 tip to the authors. .

Liu V, Morehouse JW, Soule J, Whippy A, Escobar GJ. Fluid volume, lactate values, and mortality in sepsis patients with intermediate lactate values. Ann Am Thorac Soc. 2013;10:466–73.

FREE FULL ARTICLE

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Albumin in the Initial Resuscitation of Sepsis and Septic Shock.

Several days ago I posted a comment on @iculaughingrn's page when the cited meme was posted. I guess I need to be extremely careful with my wording because I wrote "Looks like $30 of not much evidence to support its routine use in resuscitation". 

We live in a world now where every word counts and some people in the comments section let me have it. I am under a microscope and therefore this post clarifies my thought process with guidelines to support. It's also important to recognize why we do what we do or don't do. I'm not going to dissect the different albumin studies at this juncture. Maybe later. 

Healthcare as a whole in the US at this time is not sustainable. This is why I am hopeful that the HAT cocktail which is extremely cheap is successful versus one of these -NIB or -MAB drugs that costs tens of thousands of dollars. Albumin, relative to crystalloids, is extremely expensive. We need to be cognizant of these things. 

I should have written "routine use in sepsis resuscitation". The CVICU population is a completely different beast although I would LOVE to see data for albumin being beneficial in that population. I have not seen it. The burn population is one that terrifies me so kudos to all of you practicing there. I do not know your literature. 

Many of you know I am not a big fan of guidelines but this is something I can agree with. Earlier in my career I routinely used albumin. Now, I rarely use it. During my entire fellowship, albumin was not a word that was uttered in the MICU unless you were referencing the lab value.
Ultimately, the guidelines state: "The absence of any clear benefit following the administration of colloid compared with crystalloid solutions in the combined subgroups of sepsis, in conjunction with the expense of albumin, supports a strong recommendation for the use of crystalloid solutions in the initial resuscitation of patients with sepsis and septic shock."

After the initial resuscitation, the clinician needs to be the clinician. Giving fluids arbitrarily to make the BP look pretty is not something I am a fan of. Some patients may need albumin, some may not. I rarely use it in my practice, though. Use your best clinical judgement. A hat tip to the authors. 

Levy, M. M., Evans, L. E.; Rhodes, A. The surviving sepsis campaign bundle: 2018 update. Crit. Care Med. 46, 997–1000 (2018).

- EJ




Link to Article

Link to FULL FREE PDF

Levy, M. M., Evans, L. E.; Rhodes, A. The surviving sepsis campaign bundle: 2018 update. Crit. Care Med. 46, 997–1000 (2018).

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Bicarbonate in Lactic Acidosis?

I would like to make this perfectly clear, this article has many nuisances to it. Many limitations and different components that need to be dissected carefully. Too carefully for what I can do on IG. Please attempt to obtain it and read it for yourself as it does not provide a black and white response to the question: can we treat lactic acidosis with bicarb?
The slides presented here are preliminary slides from my lectures that I am actively working on. I plan on explaining things in far more detail to my audience than what is on the slides. Is that enough of a disclaimer? Well then let's let it rip!
There exists a pendulum in many things medicine and providing bicarb in lactic acidosis patients is one of them. There's always been the question of whether it's beneficial, ineffective or harmful. If you look at the data pre-2000, it is almost entirely supportive of not providing bicarb for these patients. The data after 2001 is more lenient to where it is discussed in one paper that "bicarbonate might prolong survival sufficiently to allow treatment of the underlying cause of lactic acidosis". This is why I use the term "bicarb band-aid" whenever I put someone on a bicarb drip to buy some time to figure things out. 
Like everything in medicine, bicarb drips have their drawbacks. I know people LOVE to give amps of bicarb during ALCS but there's no data to do so. Much more to that than what I'm going to discuss here. Very broad topic. 
Getting back to the article. They took almost 400pts in France who were very sick, with a lactic acidosis, and randomized them to get either nothing or 4.2% bicarb gtt. They had some very strange outcomes which are a conversation for another day but ultimately, patients who had acute kidney injury did better, and this is even considering that 24% of the control group got bicarb. Nonetheless, the numbers are explained in the slides. 
Again, is this black and white? Nope. But it's the first large RCT in this patient population looking at this intervention and major hat tips to the authors. 

-EJ

PS: Can I take credit for the term "bicarb band-aid"? I'd like to but I feel that I'm not original enough to have come up with it. 





Link to Article

Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet 2018; 392:31.

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