Thread by @GasBugZa

Next up is Prof Mette Berger - 'Small Things Matter - The Importance of Micronutrients'
I love these talks, because there is such a personal knowledge gap, I always feel like I learn so much!
#CCSSA2022 #critcare #FOAMcc

What micronutrients are important? Its the ESSENTIAL MICRONUTRIENTS that we need to worry about. They are critical for numerous aspects of critical care, including wound healing and immunity.
A great review - doi.org/10.3390/nu1201…
#CCSSA2022

Prof Berger's interest in micronutrients started decades ago, when she assessed the micronutrient losses in burns patients from burns exudates - massive losses of zinc, copper & selenium - this work to led to the modern paradigm of supplementing these in burns ICUs.
#CCSSA2022

Intensivists generally monitor iron, administer thiamine, but relatively little else - check out this recent paper on current practice in European critical care.
doi.org/10.1016/j.clnu…
#CCSSA2022

The micronutrients of most interest in critical care are:
Vitamin B1 - Thiamine
Vitamin C
Vitamin D3
Iron
Copper
Selenium
Zinc
Check out the 2022 ESPEN Micronutrient Guidelines - doi.org/10.1016/j.clnu…
#CCSSA2022

Thiamine is interesting - no real stores of it exist. Its absence can lead to profound hyperlactataemia. It should be supplemented in those at risk of refeeding syndrome. It should

Vitamin C is an essential antioxidant, used throughout the body. Studies on supplementation in ICU involve high doses of 50mg/kg - the equivalent of hundreds of oranges per day!
doi.org/10.1097/MCO.00….
#CCSSA2022

The relevant major trials regarding Vit C in CC. There are problems with all these trials, little uniformity in other care so hard to make conclusions.doi.org/10.1001/jama.2…
doi.org/10.1001/jama.2…
doi.org/10.1056/NEJMoa…
#CCSSA2022

Vit D 3 has a high incidence of low levels in critically ill patients, even in those presenting to emergency departments.
doi.org/10.1136/emerme…

Copper has been ignored for a long time, usually ignored as thought to be potentially toxic. The ESPEN guidelines recommends measuring copper levels in a variety of patients including post-bariatric, neuropathy, major burns, CRRT, long term PN patients. (link above) #CCSSA2022

Copper is essential for the function of oxydo-reductive mechanisms, iron transport, dopamine metabolism, cytochrome C oxidase, collagen formation. Levels below <12umol/L should probably be supplemented, <8umol/L should definitely be.
#CCSSA2022

Iron is controversial, but for the first time in critically ill patients the ESPEN guidelines suggest it is supplemented in those with very low levels. IRONMAN was the study of note, but the study also had problems.
doi.org/10.1007/s00134…
#CCSSA2022

The deficit of one micronutrient blocks multiple processes, so the supplementation of one when multiple others are also deficient will often lead to no effect. The trick is to target them all, but not to aim for supernormal levels!
doi.org/10.1186/s13054…
#CCSSA2022