Clinical Management of Endotoxemia: Metabolic and Nutritional Support

Description

Metabolic endotoxemia is a systemic condition in which increased plasma lipopolysaccharide (LPS) levels induced by infections may lead to chronic inflammation-related diseases and hyperinflammation. Microbiota is considered the primary source of endotoxins and LPS. Critically ill patients, highly susceptible to metabolic and inflammatory dysfunction, may present increased tight junctions' permeability, altering the absorption of nutrients and allowing the bacteria translocation. Early recognition followed by prompt initiation of antimicrobial provision, fluid resuscitation, and supportive care measures remains the cornerstone of septic shock management. Although enteral nutrition (EN) has been shown to preserve gut epithelial barrier function reversing gut dysbiosis, there is no direct evidence on adjustment required for the EN rate in patients with septic shock. Early parenteral nutrition (PN) may be a safe option when early EN will not or cannot be provided. Unfortunately, available controlled clinical trials on the efficacy of PN are not well designed, and most of them are limited to a small number of patients, different critical illnesses, and inappropriate blinding strategies. Although emergent literature favors a probiotic supplementation for enhancement of barrier function, preventing endotoxin influx, we have conflicting results in the literature. A new frontier is represented by donor microbiota that can engraft in the recipient, increasing the microbiota diversity and restoring normal bowel function. Further studies are needed; its impact on immunosuppressed patients with an altered microbiome is unknown and has at least theoretical risks.

Additional details