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The Impact of Sarcopenia on Intensive Care Unit Patients: Implications for COVID-19

Intensive Care Unit Capacity and COVID-19:

When reports of COVID-19 cases in the United States began to emerge in March 2020, discussions about ICU capacity began to move from the medical community to the mainstream media. Although the U.S. leads the world in terms of ICU capacity with 34.7 ICU beds/100,000 inhabitants representing triple the capacity in countries such as Italy, France and South Korea, there were serious concerns that our ICU capacity would not be sufficient to address a surge in COVID-19 cases. As a result, President Trump issued an Executive Order in which he ordered General Motors and Ford to begin manufacturing ventilators, a critical medical device necessary to care for an ICU patient. In this Blog, we will explore the impact that sarcopenia has on ICU patients with a discussion of relevant clinical studies. Many clinical studies have reported that non-sarcopenic ICU patients have a significantly lower mortality risk when compared with sarcopenic patients.


Figure 1: Intensive Care Unit Capacity in Selected Countries. Reproduced from [1].






















The Impact of Skeletal Muscle Mass on Ventilator-Free Days, ICU-Free Days and Mortality in Elderly ICU Patients

In 2013, a clinical study was conducted at the University of Texas Health Science Center, Houston to examine the impact of sarcopenia on ventilator-free days, ICU-free days and mortality among elderly patients admitted in the ICU at Texas Memorial Hermann Hospital, a Level 1 Trauma Center [2].

· 149 severely injured elderly patients (median age = 79 years) (Table 1) were enrolled in the clinical study, of which 106/149 were sarcopenic.

· Muscle cross-sectional area at the 3rd lumbar vertebra was quantified from CT images and muscle index, a normalized measure of muscle mass, was calculated and related to clinical parameters such as ventilator-free days, ICU-free days, and mortality.

Among patients with sarcopenia, the mortality rate was 32% (34/106) while for non-sarcopenic patients, the mortality rate was much lower, 14% (6/43). ICU patients with sarcopenia had far fewer ventilator-free days and ICU-free days in comparison to patients that were non-sarcopenic (Table 2).


Table 1: Diagnostic Characteristics of Injured Elderly Patients at the Time of ICU Admission, Texas Memorial Hermann Hospital. Reproduced from Table 2 in [2].



Table 2: The Impact of Sarcopenia on Ventilator-Free Days and ICU-Free Days Among Elderly ICU Patients, Texas Memorial Hermann Hospital. From [2].



The Impact of Sarcopenia on Ventilator-Weaning Difficulty Among Surgical ICU Patients

In 2019, Researchers at Likou Chang Gung Memorial Hospital, Taiwan studied the impact of sarcopenia on patients recovering from surgery in the ICU [3].

· 96 patients (average age = 73 years old) that were undergoing mechanical ventilation in the surgical ICU were enrolled in the clinical study. The demographic characteristics of these patients are summarized in Table 3.

· Using CT imaging, the total psoas muscle area (TPA) was measured at the level of the 3rd lumbar vertebra.

As summarized in Table 4, sarcopenia had a major impact on patients becoming difficult-to-wean and on mortality in the ICU with odds ratios of 4.767 and 5.071 respectively. Sarcopenia was concluded to be an independent risk factor for difficulty weaning from mechanical ventilation and mortality among these critically ill ICU patients.


Table 3: Demographic Characteristics of Elderly Patients at the Time of ICU Admission, Likou Chang Gung Memorial Hospital. Reproduced from Table 1 in [3].


Table 4: The Impact of Sarcopenia on Weaning Difficulty from Mechanical Ventilation and ICU Mortality Among Elderly, Surgical ICU Subjects, Likou Chang Gung Memorial Hospital, Taiwan. From [3].



The Impact of Sarcopenia on Aspiration Pneumonia Survival in Elderly Patients

Pneumonia is one of the serious complications associated with some cases of COVID-19. Researchers at Tamana Regional Health Medical Center, Kumamoto, Japan investigated the impact of muscle mass on 90 day survival in cases of aspiration pneumonia [4].

• 151 subjects participated in this prospective, observational study with a mean age = 85.9 years (49.7% male, 50.3% female).

• Appendicular Skeletal Muscle Index (ASMI) (appendicular skeletal muscle mass / height squared) was measured; muscle mass was measured using bioelectrical impedance analysis (BIA).

• AP was diagnosed when the three criteria below were fulfilled:

o New gravity-dependent shadow on chest radiography or CT.

o Two or more of leukocytosis, fever, purulent sputum and high C-reactive protein level.

o Positive for simple dysphagia (water or food swallowing test).

As illustrated in Figure 2, patients in the lowest 25% with respect to ASMI had much poorer 90-day survival when compared with patients in the top 75% with respect to ASMI.

Figure 2: The Impact of Sarcopenia on 90 Day Survival Follow Apsiration Pneumonia Among Elderly Subjects, Tamana Regional Health Medical Center, Japan. Reproduced from [4]. Solid line represents patients in the top 75% with respect to ASMI. Dashed line represents patients in the bottom 25% with respect to ASMI.



Advanced Nutrition to Address Muscle Health:

As of today, there are no peer reviewed publications on the impact of sarcopenia on COVID-19 patients. Patients suffering from severe cases of COVID-19 will require hospitalization and possibly, admission to the ICU. Based on the studies discussed in this Blog, our hypothesis is that ICU survival is likely to be higher in COVID-19 patients admitted to the ICU that have greater muscle mass and strength relative to sarcopenic patients. Therefore it is very important that older adults make muscle health a key priority, ensuring that they meet their recommended daily allowance (RDA) for protein intake and perform some resistance training exercises on a regular basis after consulting with a Physician.

Fortetropin® is an advanced nutrition product made from fertilized chicken egg yolk using a patented, low temperature manufacturing process [5,6] that helps to better retain the natural bioactivity of the proteins, peptides and lipids that are found to be present within fertilized, chicken egg yolk. In human clinical studies, Fortetropin® has been shown to increase the rate of muscle protein synthesis [7] and lead to gains in muscle mass and strength [8].

Learn more about how Fortetropin® can help older adults improve their muscle health at www.myoslongevity.com.

References

1. McCarthy, Niall. “The Countries With The Most Critical Care Beds Per Capita [Infographic].” Forbes Magazine, March 12, 2020. https://www.forbes.com/sites/niallmccarthy/2020/03/12/the-countries-with-the-most-critical-care-beds-per-capita-infographic/#505f01a07f86

2. Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, Bulger E, Kozar RA, Nutrition and Rehabilitation Investigators Consortium. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Critical care. 2013 Oct 1;17(5):R206.

3. Kou HW, Yeh CH, Tsai HI, Hsu CC, Hsieh YC, Chen WT, Cheng HT, Yu MC, Lee CW. Sarcopenia is an effective predictor of difficult-to-wean and mortality among critically ill surgical patients. PloS one. 2019;14(8).

4. Maeda, Keisuke, and Junji Akagi. "Muscle mass loss is a potential predictor of 90‐day mortality in older adults with aspiration pneumonia." Journal of the American Geriatrics Society 65.1 (2017): e18-e22.

5. Buxmann, Waldermar, et al. “Process for producing a composition for increasing muscle mass.” S. Patent # 10,165,785, Issue Date: January 1, 2019.

  1. Buxmann, Waldermar, et al. “Process for producing a composition containing active follistatin.” S. Patent #8,815,320, Issue Date: August 26, 2014.

  2. Evans, William J., et al. “Effects of Fortetropin® on the rate of muscle protein synthesis in older men and women: a randomized, double blinded, placebo-controlled study.” Gerontol Med Sci, submitted.

  3. Sharp, Matthew H., et al. "The effects of fortetropin supplementation on body composition, strength, and power in humans and mechanism of action in a rodent model." Journal of the American College of Nutrition8 (2016): 679-691.

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