Publications by authors named "A R H van Zanten"

233 Publications

Micronutrient deficiencies in critical illness.

Clin Nutr 2021 Jun 11;40(6):3780-3786. Epub 2021 May 11.

Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, the Netherlands; Division of Human Nutrition and Health, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, the Netherlands. Electronic address:

Background & Aims: Low micronutrient levels in critical illness have been reported in multiple studies. Because of the antioxidant properties of various micronutrients, micronutrient deficiency may augment oxidative stress in critical illness. However, it remains unclear whether micronutrient concentrations in ICU patients are different from those in healthy age-matched controls. It is also unclear whether micronutrient deficiency develops, worsens, or resolves during ICU admission without supplementation.

Methods: We prospectively studied a cohort of adult critically ill patients. Micronutrient levels, including selenium, β-carotene, vitamin C, E, B and B were measured repeatedly during the first week of ICU admission. We compared the micronutrient concentrations at ICU admission to those of healthy age-matched controls. In addition, associations between micronutrient concentrations with severity of illness, inflammation and micronutrient intake were investigated.

Results: Micronutrient blood concentrations were obtained from 24 critically ill adults and 21 age-matched healthy controls. The mean micronutrient levels at admission in the ICU patients were: selenium 0.52 μmol/l, β-carotene 0.17 μmol/l, vitamin C 21.5 μmol/l, vitamin E 20.3 μmol/l, vitamin B 129.5 nmol/l and vitamin B 41.0 nmol/l. In the healthy controls micronutrient levels of selenium (0.90 μmol/l), β-carotene (0.50 μmol/l), vitamin C (45 μmol/l) and vitamin E (35.5 μmol/l) were significantly higher, while vitamin B (122 nmol/l) and B (44 nmol/l) were not significantly different between patients and controls. Selenium, vitamin B and vitamin B levels remained stable during ICU admission. Vitamin C levels dropped significantly until day 5 (p < 0.01). Vitamin E and β-carotene levels increased significantly on days 5-7 and day 7, respectively (p < 0.01). Micronutrient levels were not associated with severity of illness, CRP or micronutrient intake during the admission.

Conclusions: At admission, ICU patients already had lower plasma levels of selenium, β-carotene, vitamin C and vitamin E than healthy controls. Vitamin C levels dropped significantly during the first days of ICU admission, while β-carotene and vitamin E levels increased after 5-7 days. No association between micronutrient levels and severity of illness, C-reactive protein (CRP) or micronutrient intake was found. Progressive enteral tube feeding containing vitamins and trace elements does not normalize plasma levels in the first week of ICU stay. This was a hypothesis generating study and more investigation in a larger more diverse sample is needed.
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http://dx.doi.org/10.1016/j.clnu.2021.05.003DOI Listing
June 2021

Case series of four secondary mucormycosis infections in COVID-19 patients, the Netherlands, December 2020 to May 2021.

Euro Surveill 2021 06;26(23)

Center for Infectious Disease Research, Diagnostics and Laboratory Surveillance National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.

We describe four secondary fungal infections caused by Mucorales species in COVID-19 patients. Three COVID-19 associated mucormycosis (CAM) occurred in ICU, one outside ICU. All were men aged > 50 years, three died. Clinical presentations included pulmonary, rhino-orbital cerebral and disseminated infection. Infections occurred in patients with and without diabetes mellitus. CAM is an emerging disease and our observations underscore the need to be aware of invasive mucormycosis, including in COVID-19 patients without (poorly controlled) diabetes mellitus and outside ICU.
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http://dx.doi.org/10.2807/1560-7917.ES.2021.26.23.2100510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193993PMC
June 2021

Bioelectric impedance analysis for body composition measurement and other potential clinical applications in critical illness.

Curr Opin Crit Care 2021 08;27(4):344-353

Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede.

Purpose Of Review: Insight into body composition is of great value in the ICU. Bioelectric impedance analysis (BIA) is the most applicable bedside technique. However, bioimpedance has not been validated in the critically ill, and the interpretation of the measurements poses challenges. This review discusses the potential clinical applications of BIA and explores caveats and solutions to its use in the intensive care setting.

Recent Findings: A correlation is repeatedly found between raw impedance parameters, fluid ratios, overhydration, and adverse outcome of critical illness. However, cut-off and reference values remain elusive. Experience with BIA-guided fluid management in the ICU is limited. BIA-derived muscle mass appears a promising biomarker for sarcopenia, correlating well with CT-analysis. Body cell mass and fat-free mass provide potential use in estimation of metabolic rate, protein requirements and pharmacokinetics. Several methods of reducing bias in BIA parameters in critical illness require validation.

Summary: There are currently too many uncertainties and discrepancies regarding interpretation of bioimpedance in critical illness, to justify therapeutic consequences. However, there are several promising areas of research, concerning some of the most urgent clinical problems in intensive care, emphasizing the need to evaluate further the use and interpretation of bioimpedance in the intensive care setting.
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http://dx.doi.org/10.1097/MCC.0000000000000840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270506PMC
August 2021

Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations.

J Intensive Care 2021 Jan 12;9(1). Epub 2021 Jan 12.

Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, RP, Ede, The Netherlands.

The use of indirect calorimetry is strongly recommended to guide nutrition therapy in critically ill patients, preventing the detrimental effects of under- and overfeeding. However, the course of energy expenditure is complex, and clinical studies on indirect calorimetry during critical illness and convalescence are scarce. Energy expenditure is influenced by many individual and iatrogenic factors and different metabolic phases of critical illness and convalescence. In the first days, energy production from endogenous sources appears to be increased due to a catabolic state and is likely near-sufficient to meet energy requirements. Full nutrition support in this phase may lead to overfeeding as exogenous nutrition cannot abolish this endogenous energy production, and mitochondria are unable to process the excess substrate. However, energy expenditure is reported to increase hereafter and is still shown to be elevated 3 weeks after ICU admission, when endogenous energy production is reduced, and exogenous nutrition support is indispensable. Indirect calorimetry is the gold standard for bedside calculation of energy expenditure. However, the superiority of IC-guided nutritional therapy has not yet been unequivocally proven in clinical trials and many practical aspects and pitfalls should be taken into account when measuring energy expenditure in critically ill patients. Furthermore, the contribution of endogenously produced energy cannot be measured. Nevertheless, routine use of indirect calorimetry to aid personalized nutrition has strong potential to improve nutritional status and consequently, the long-term outcome of critically ill patients.
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http://dx.doi.org/10.1186/s40560-021-00524-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801790PMC
January 2021

Electrolyte disorders during the initiation of nutrition therapy in the ICU.

Curr Opin Clin Nutr Metab Care 2021 Mar;24(2):151-158

Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands.

Purpose Of Review: To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition.

Recent Findings: Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome.

Summary: Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.
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http://dx.doi.org/10.1097/MCO.0000000000000730DOI Listing
March 2021