Several advanced and developing countries are now entering a superaged society, in which the percentage of elderly people exceeds 20% of the total population. In such an aging society, the number of age-related diseases such as malignant tumors, diabetes, and severe infections including sepsis is increasing, and patients with such disorders often find themselves in the ICU.
Age-related diseases are closely related to age-induced immune dysfunction, by which reductions in the efficiency and specificity of the immune system are collectively termed “immunosenescence.” The most noticeable is a decline in the antigen-specific acquired immune response. The exhaustion of T cells in elderly sepsis is related to an increase in nosocomial infections after septicemia, and even death over subacute periods. Another characteristic is that senescent cells that accumulate in body tissues over time cause chronic inflammation through the secretion of proinflammatory cytokines, termed senescence-associated secretory phenotype. Chronic inflammation associated with aging has been called “inflammaging,” and similar age-related diseases are becoming an urgent social problem.
In ICUs, several diseases including stroke and sepsis are related to immunosenescence and neuroinflammation in the elderly. Several advanced countries with superaged societies face the new challenge of improving the long-term prognosis of critical patients.
Lessening morbidity and mortality, and improving survival rate are the goals of surgical team. The nutritional management has been tremendously helped reduce morbidity and mortality. Nutritional support also improves postoperative outcomes especially in malnourished or undernourished patients, old patients and critically ill patients. Therefore, it is also important to screen highly susceptible group. With screening, administering adequate nutrition and restoring them to proper status of nutrition preoperatively can be possible.
Recently ERAS program has been well propagated in many fields of surgery. Adoption of ERAS program reduces the stressful effect of the surgery and facilitates recovery as well. There are many reports that ERAS program improves the patient’s outcomes. This multi-disciplinary approach finds the optimal treatment for the individual patient. Among ERAS, minimal invasive surgery will play an important role for reducing morbidity.
Recently minimal invasive surgery has been well propagated due to its advantages of early recovery and reduced morbidity. Therefore it will be good for the patients if we can combine ERAS with minimal invasive surgery.
The inflammation including postoperative complications is associated poor survival of the patients. Various efforts should be made to decrease postoperative complications including infectious complications. For this, minimize inflammatory status is needed, including antibiotic and adequate preventions of infection. Another way is to perform precise and meticulous operations. With this strategy in mind, morbidity and mortality will decrease and survival of the patients will be improved.
In conclusion, the new way for optimal patient care combining ERAS with precise minimal invasive surgery（ERAS plus PMIS）will prevail in the future.
Although the importance of nutritional therapy has been emphasized in nutritional guidelines for critically ill patients, there are few studies demonstrating the strong evidence of the nutritional therapy on long-term outcomes. Critical illness is associated with hypermetabolism and marked protein catabolism, and therefore muscle wasting is a frequent finding. Muscle loss and weakness seen in clinically has been associated with impaired function and poor clinical outcomes. Several international guidelines suggested that high doses of protein in the range of 1.2-2.0 g/kg/day may be required in the setting of the intensive care unit. However, we are not sure what the effect of administration exogenous protein/amino acids on muscle protein synthesis and balance during anabolic response. In another view, how can we optimize the doses of protein/ amino acids and what is the difference between via enteral and parenteral? Do we need the change of doses of protein/ amino acids for adjust the baseline of muscle volume in each patient, such as between young and elderly patients? Thus, we have many questions for protein delivery. The incidence of sarcopenia and frailty in the elderly has been increasing towards the future in Japan, and therefore, the number of critically-ill elderly patients with various degrees of malnutrition is also increasing. Optimal nutritional therapy needs to be initiated on admission to the intensive care unit. Although there is no definitive consensus, optimal provision of energy and protein to maintain muscle mass to maintain function is a mainstay. We are still in the inextricable maze for critically ill patients.
Advances in parenteral nutrition（PN）support revolutionized the management of patients with intestinal failure in infants. Long term PN induces the liver disease in these infants. Parenteral nutrition associated liver disease（PNALD）presents with jaundice（a serum direct bilirubin concentration＞2 mg/dL）, and failure of thrive. Incidence of PNALD is 25% to 60% in infants receiving long term PN and the mortality with PNALD was reported 100% at 1 year of diagnosis unless they were weaned off PN or received liver/small bowel transplantation.
Although etiology of PNALD is multifactorial（prolonged duration of PN, enteral nutrition intolerance, preterm birth, low birth weight, septicemia, overfeeding, and micronutrient imbalances）, soybean lipid emulsion（SOLE）is a major risk factor of pathogenesis of PNALD. SOLE contains high amount of phytosterols which contribute to the development of cholestasis. The large amount of omega-6 fatty acid and relatively paucity of antioxidants in SOLE may potentiate inflammation and liver injury.
Fish oil lipid emulsion（FOLE）at 1g/kg per day replacement of SOLE shows resolution of biochemical cholestasis with significant decreases in morbidity and mortality. The mechanism of FOLE for PNALD may be from differences in its components of FOLE that contains minimal phytosterol and is rich in omega-3 fatty acid and alpha-tocopherol. The strategy of FOLE monotherapy for infants with PNALD increased survival and many infants with intestinal failure remained alive with long term PN without liver/small bowel transplantation.
Despite these good outcomes, FOLE monotherapy may induce essential fatty acid deficiency（EFAD）because FOLE have relatively small amount of linoleic acid（LA）and alpha linolenic acid（ALA）.However, FOLE monotherapy does not lead to the development of EFAD.
Intestinal rehabilitation team of Samsung Medical Center consisting of a pediatric surgeons, pharmacists, clinical dietitian, and specialized nursing staff applied FOLE monotherapy to infants with PNALD. We have good results.