Objective: Enteral diets enriched with eicosapentaenoic acid (EPA), γ-linolenic acid (GLA) and antioxidant vitamins have been demonstrated to improve outcomes in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). There is ethnic difference in the distribution of genetic polymorphisms, and therefore, the efficacy of nutritional treatment may differ among races. We evaluated the efficacy of the enteral diet enriched with EPA, GLA and antioxidants in a Japanese-descendant population with ARDS secondary to severe sepsis or septic shock through a retrospective assessment of the original database of our previous study. Materials and methods: 18 Japanese-descendant patients were identified from the original study based on the ethnic answer on their clinical research forms. All patients were randomly assigned to two groups either with a diet enriched with EPA, GLA and antioxidant vitamins or with an isonitrogenous and isocaloric control diet, delivered at a constant rate to achieve a minimum of 75% of basal energy expenditure x 1.3 during a minimum of 4 days and monitored for 28-days. Results: Those who received the study diet experienced significant improvements in oxygenation status, more ventilator-free days (12.0±2.6 vs. 4.2±1.7, P = 0.0362) and more ICU-free days (8.9±2.2 vs. 2.6±1.2, P = 0.0348). No significant changes were observed in terms of the development of new organ failures and mortality outcomes. Conclusions: In Japanese-descendant patients with severe sepsis or septic shock and requiring mechanical ventilation and tolerating enteral nutrition, a diet enriched with EPA, GLA and antioxidants contributed to better ICU outcomes.
Previous reports have indicated that intravenous immunoglobulin (IVIG) preparation reduces some types of inflammatory cytokines. In the present study, we investigated the short-term and direct effects of IVIG in 16 patients with sepsis. Following the administration of 5 g of IVIG for 1 hour, we took blood samples immediately following IVIG treatment and at 1 hour after IVIG treatment. Blood samples taken at 1 hour and just prior to IVIG administration were used as controls. While there was no difference between 1 hour before and just prior to IVIG treatment, statistically significant decreases were observed in the levels of interleukin-6 (IL-6) after the administration of IVIG. No significant changes were observed in the plasma levels of tumor necrosis factor-α and high mobility group box 1. We confirmed the results of previous animal studies. While we reported that the administration of IVIG directly reduces the plasma levels of IL-6 in patients with sepsis, a further prospective study of the anti-cytokine effects following IVIG treatment will be conducted in the near future.
Objective: Pulmonary edema is divided into cardiogenic and permeability types. There are no quantitative diagnostic criteria for differentiating between the pathologic mechanisms. The purpose of this study is to establish quantitative differential criteria for cardiogenic pulmonary edema and acute lung injury/acute respiratory distress syndrome (ALI/ARDS) (permeability edema). Methods: In this multicenter study, 91 patients ventilated for acute respiratory failure with a P/F ratio < 300 and bilateral infiltration on chest radiographs, necessitating transpulmonary thermodilution technique monitoring, were enrolled. We assessed the pulmonary vascular permeability index (PVPI) as the extravascular lung water index (ELWI)/pulmonary blood volume index. Pulmonary edema was defined as ELWI > 10 ml/kg. The cause of pulmonary edema was determined by three or more experts, taking into account medical history, clinical features, respiratory and hemodynamic variables, and clinical course with therapy. The experts were blinded to the PVPI data. Results: ALI/ARDS was diagnosed in 58 cases, pleural effusion/atelectasis in 11, and cardiogenic pulmonary edema in 6 (16 suspected cases). The ELWI of pleural effusion/atelectasis was below that of pulmonary edema (7.7±1.2 ml/kg). The PVPI in ALI/ARDS was significantly higher than that of non-ALI/ARDS (ALI/ARDS, 2.91±0.92; pleural effusion/atelectasis, 1.51±0.55; cardiogenic pulmonary edema, 1.53±0.31). The area under the curve (AUC) of receiver operating characteristic (ROC) curve using the PVPI to distinguish ALI/ARDS from non-ALI/ARDS was 0.926. A PVPI of 2.0–2.2 was thus proposed as the differential value. There was a positive correlation between PVPI and ELWI in ALI/ARDS (Sr = 0.652, P < 0.001), but not in non-ALI/ARDS. Conclusions: PVPI combined with ELWI may be useful for determining the pathologic mechanisms of pulmonary edema and respiratory failure in the critical care setting. (UMIN-CTR number, UMIN 000003627)