Interviewee: Medicine and a past president of the World Federation Of Intensive Care Societies. You can say before that I am professor of intensive care medicine at the University of Brussels.
Interviewer: Just from the topic of [unintelligible 00:00:20] legal trials. Be good to have some conclusion about that as well. Doctors could say it's difficult to get information. Where does that leave us, what are the challenges today, or what are we moving forward-- [crosstalk]
Interviewee: I can do that [unintelligible 00:00:33]
Interviewer: Yes, pretty popular people [unintelligible 00:00:36] if you like. Good to go? I'm here to [unintelligible 00:00:40] Jean [unintelligible 00:00:41] it's an honor to have you here. We are at the [unintelligible 00:00:45] if he looks familiar, that's fine, he's capturing everything. [laughs] We are at the 32nd [unintelligible 00:00:53] meeting here in Berlin. Jean Louis is our president, also past president of the World Federation Of Intensive Care and is currently [unintelligible 00:01:03] professor in [unintelligible 00:01:05]. We were discussing earlier about the treatable [unintelligible 00:01:11] with outcomes as clinical nutrition [unintelligible 00:01:16] Can you expand on that to what critical [unintelligible 00:01:20]
Interviewee: It's not only on studies on nutrition. It is in general. Today everybody speaks about the negativity of our trials. We are in some kind of depressive phase where all trials do not show any difference in outcomes. This is true for nutrition as well as for other things. We had a round table conference on this. On nutritional issues in Brussels last year and the outcome just came out in critical care a few days ago. We reviewed this literature and we realized, and I speak about it this afternoon actually, we realized that every single study was on critically ill patients. Critically ill patients. Critically ill patients. Targeting mortality. How do you want to change mortality in a mixed population of ICU patients? It does not make sense, it's not achievable. There are two things we should do, and again that's what I will discuss this afternoon. One is we should no longer focus only on mortality, and especially with nutrition. How do you think it will influence mortality? When you nourish people properly you expect them to become stronger, recover a good muscle force, and be more quickly rehabilitated. That's what we should look at.
Secondly, we should stop putting all the patients in the same group in the same bag. Patients early after trauma are very different from patients who have been septic for 10 days, and very different from patients with heart failure who may stay in the hospital for several weeks because they are in a bad condition. So, why do we put all these patients in the same trial? We should stop doing that and then we will start to see some important things emerging. Nutrition is so important. Don't tell me you can eat whatever you like, the outcome will be the same. That's not true, it cannot be true. We need to personalize the nutritional support including with vitamins, with [unintelligible 00:03:36] elements et cetera. We need to measure what we do.
Interviewer: So why now, do you think it's because there've been so many trials that have been homogenously grouped? We've realized now it hasn't worked or why after all these years we come up with what should be clear?
Interviewee: I have said it for years.
[laughter]
People smile and say, "Well, that's the way it is." The paper is published in the New England Journal because there are 3,000 patients involved but it's a negative study. Negative study. Negative study. At the end, you can criticize everything. Now the big thing is undernutrition. Massive undernutrition. What's going on? At the end, we will stop nourishing our patients? No way. That's very important.
Interviewer: Very important. On a practical note, what do you do in your intensive care? How do you assist your patients?
Interviewee: We published it in the Lancet not so long ago. We start enteral nutrition as soon as possible when it's possible. That means since admission. We start it usually we increase the number of calories progressively, although, in some patients like those after a head injury, you may start quite quickly and increase it quite quickly. That's how I don't believe so much in protocolized care. I think we need to individualize these decisions, and so we try to achieve 25 calories per kilogram as a general rule. We try to give 1.3 g of protein per kilogram per day as a general rule. That's the stronger recommendation. We do not use indirect calorimetry to assess the exact number of calories that the patient may need. It's probably something we should do. I believe in measurement, as I say, we need to individualize this therapy. Right now we do not have the instruments available but in complex cases that would be something to do.
Interviewer: You're not too far away from the guidelines, what you're doing? [crosstalk]
Interviewee: The guidelines are not very precise. Like all guidelines, they don't say very much. Of course, the guidelines are good, I've nothing against guidelines. I participated in many guidelines in other fields.
Interviewer: For the next test what do you think is needed now to come up with some concrete help for those that are not well informed?
Interviewee: We need to start with a good question. With a good questionnaire. Not just [unintelligible 00:06:19] from the beginning. That doesn't make sense. If you can use your gut, use your gut. That kind of question is stupid. Let's go for a good question and let's address the question in a relatively homogeneous group of patients, like in the early stages or in the later stages of the disease process. Then let's look at organ function and strength and physical fitness. Of course, we can look at mortality, but mortality should not be the primary endpoint, that's ridiculous to look at mortality for all studies. We need to have better endpoints as well. Better patient population and better endpoints for a good question. That's all, and we will succeed.
Interviewer: Thank you very much, it's pleasure.
Interviewee: Thank you.
Interviewer: That was very interesting, thank you.