Metabolic and nutritional support of critically ill patients: consensus and controversies

The Role of Dysbiosis in Critically Ill Patients With COVID-19 and Acute Respiratory Distress Syndrome

In late December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) quickly spread worldwide, and the syndrome it causes, coronavirus disease 2019 (COVID-19), has reached pandemic proportions. Around 30% of patients with COVID-19 experience severe respiratory distress and are admitted to the intensive care unit for comprehensive critical care. Patients with COVID-19 often present an enhanced immune response with a hyperinflammatory state characterized by a "cytokine storm," which may reflect changes in the microbiota composition. Moreover, the evolution to acute respiratory distress syndrome (ARDS) may increase the severity of COVID-19 and related dysbiosis. During critical illness, the multitude of therapies administered, including antibiotics, sedatives, analgesics, body position, invasive mechanical ventilation, and nutritional support, may enhance the inflammatory response and alter the balance of patients' microbiota. This status of dysbiosis may lead to hyper vulnerability in patients and an inappropriate response to critical circumstances. In this context, the aim of our narrative review is to provide an overview of possible interaction between patients' microbiota dysbiosis and clinical status of severe COVID-19 with ARDS, taking into consideration the characteristic hyperinflammatory state of this condition, respiratory distress, and provide an overview on possible nutritional strategies for critically ill patients with COVID-19-ARDS.

Replacing protein via enteral nutrition in a stepwise approach in critically ill patients: A pilot randomized controlled trial (REPLENISH pilot trial)

BACKGROUND AND AIMS

The optimal amount of protein intake in critically ill patients is unclear. The objective of this pilot trial is to assess the feasibility of a large randomized controlled trial testing higher versus lower protein intake in critically ill patients.

METHODS

In this pilot randomized controlled trial (REPLacing Protein via Enteral Nutrition in a Stepwise ApproacH in critically ill patients: A pilot randomized controlled trial (REPLENISH pilot trial), critically ill patients underwent 2-step screening for eligibility on ICU day 1 and 5. Patients with renal disease were excluded. Eligible patients were randomized into REPLENISH group (target protein 1.8-2.2 g kg/day) and Standard group (target protein 0.8-1.0 g/kg/day) from day 6-14 after ICU admission. Dietitians adjusted caloric and protein intake throughout the study period (Day 1-14) to maintain similar caloric targets of permissive underfeeding (40-60% of estimated energy expenditure) in both study groups.

RESULTS

Of 704 patients screened at 3 centers in Saudi Arabia from May 2018 to May 2019, only 63 (8.9%) were eligible and 40 (5.7% of screened) were randomized with an average of 2 patients enrolled in the trial per month. Among eligible patients, the consenting rate was high at 89%. During the intervention period, patients in the REPLENISH group (N = 21) had a modestly higher protein intake (median of 1.30 g/kg/day (Q1 Q3: 1.11, 1.57)) than those in the standard group (median of 0.77 g/kg/day (Q1 Q3: 0.57, 1.00); P = 0.0004). Only 31.4% of patients in the whole cohort had >80% of prescribed protein. The duration of daily interruption of feeding was almost 4 h in both groups. The 90-day mortality for the patient study cohort was 20.5%. Anthropometric and muscle strength measurements were performed in less than 50% of patients.

CONCLUSIONS

This pilot trial highlighted several areas for improvement in the study protocol before launching a large randomized controlled trial. The restrictive eligibility criteria, the complex adjustments of protein and energy and some of the outcome measurements were identified as targets for modifications, to improve enrollment and generalizability and to enhance adherence to study interventions and measurements.

TRIAL REGISTRATION

CLINICALTRIALS.

GOV IDENTIFIER

NCT03480555.

The goldilocks problem: Nutrition and its impact on glycaemic control

BACKGROUND

Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. Glycaemic control (GC) may improve outcomes, though safe and effective control has proven elusive. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. This study aims to examine BG outcomes in the context of nutritional management during GC.

METHODS

Retrospective cohort analysis of 5 glycaemic control cohorts spanning 4 years (n = 273) from Christchurch Hospital Intensive Care Unit (ICU). GC is delivered using a single model-based protocol (STAR), with default 4.4-8.0 mmol/L target range via. modulation of insulin and nutrition. Clinical adaptations/cohorts include variations on upper target (UL-9 with 9.0 mmol/L, reducing workload and nutrition responsiveness), and insulin only (IO) with clinically set nutrition at 3 glucose concentrations (71 g/L vs. 120 and 180 g/L in the TARGET study).

RESULTS

Percent of BG hours in the 4.4-8.0 mmol/L range highest under standard STAR conditions (78%), and was lower at 64% under UL-9, likely due to reduced time-responsiveness of nutrition-insulin changes. By comparison, IO only resulted in 64-69% BG in range across different nutrition types. A subset of patients receiving high glucose nutrition under IO were persistently hyperglycaemic, indicating patient-specific glucose tolerance.

CONCLUSION

STAR GC is most effective when nutrition and insulin are modulated together with timely responsiveness to persistent hyperglycaemia. Results imply modulation of nutrition alongside insulin improves GC, particularly in patients with persistent hyperglycaemia/low glucose tolerance.

Impact of early low-calorie low-protein versus standard-calorie standard-protein feeding on outcomes of ventilated adults with shock: design and conduct of a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)

INTRODUCTION

International guidelines include early nutritional support (≤48 hour after admission), 20-25 kcal/kg/day, and 1.2-2 g/kg/day protein at the acute phase of critical illness. Recent data challenge the appropriateness of providing standard amounts of calories and protein during acute critical illness. Restricting calorie and protein intakes seemed beneficial, suggesting a role for metabolic pathways such as autophagy, a potential key mechanism in safeguarding cellular integrity, notably in the muscle, during critical illness. However, the optimal calorie and protein supply at the acute phase of severe critical illness remains unknown. NUTRIREA-3 will be the first trial to compare standard calorie and protein feeding complying with guidelines to low-calorie low-protein feeding. We hypothesised that nutritional support with calorie and protein restriction during acute critical illness decreased day 90 mortality and/or dependency on intensive care unit (ICU) management in mechanically ventilated patients receiving vasoactive amine therapy for shock, compared with standard calorie and protein targets.

METHODS AND ANALYSIS

NUTRIREA-3 is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients receiving invasive mechanical ventilation and vasoactive amine therapy for shock and given early nutritional support according to one of two strategies: early calorie-protein restriction (6 kcal/kg/day-0.2-0.4 g/kg/day) or standard calorie-protein targets (25 kcal/kg/day, 1.0-1.3 g/kg/day) at the acute phase defined as the first 7 days in the ICU. We will include 3044 patients in 61 French ICUs. Two primary end-points will be evaluated: day 90 mortality and time to ICU discharge readiness. The trial will be considered positive if significant between-group differences are found for one or both alternative primary endpoints. Secondary outcomes include hospital-acquired infections and nutritional, clinical and functional outcomes.

ETHICS AND DISSEMINATION

The NUTRIREA-3 study has been approved by the appropriate ethics committee. Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03573739.

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis

BACKGROUND

Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence.

METHODS

This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes.

RESULTS

Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P = .99), hospital LOS (mean difference, -1.44; CI, -5.59 to 2.71; P = .50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials.

CONCLUSION

A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.

Factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit

BACKGROUND & AIMS

Inadequate nutrition delivery in critically ill children has shown associated with poor clinical outcomes. Therefore, identifying barriers to deliver adequate nutrition is vital. The aim of this study was to identify factors influencing adequate protein and energy delivery among critically ill children with heart disease in pediatric intensive care unit (PICU).

METHODS

This single-centre prospective study, involved children aged from birth to 3 years old, admitted to PICU longer than 72 hours. They received either enteral nutrition (EN) or combination of EN and partial parenteral nutrition (PPN). Clinical and nutrition delivery characteristics were recorded from admission until transferred out of PICU. Multiple regression analysis at significant level p < 0.05 were used to identify independent risk factors for lower protein and energy intake.

RESULTS

One hundred and thirty-nine patients were included in this study with median age 6.5 (1.8-20.6) months and median PICU length of stay of 6 (4-7) days. The median energy and protein adequacy were 83.2% and 46.7%, respectively. In multivariable analysis, children who underwent surgery (AOR 0.97; 95% CI 0.27-0.75; p = 0.041), with fluid restriction (AOR 0.97; 95% CI 0.25-0.73; p = 0.041), longer length of PICU stay (AOR 0.35; 95% CI 0.18-0.64; p = 0.001) and longer feeding interruptions (AOR 3.57; 95% CI 1.39-9.15; p = 0.008) were more likely to have lower energy intake. Children at risk of malnutrition (weight-for-age Z score of < -2 SD) (AOR 2.54; 95% CI 1.12 to 5.77; p = 0.026) and longer duration of mechanical ventilation (AOR 0.73; 95% CI 0.53 to 0.98; p = 0.041) were more likely to have lower protein intake.

CONCLUSION

This study highlighted the factors influencing adequate protein and energy delivery in critically ill children with heart disease in PICU. Strategies to improve the nutrition delivery in this group of patients should be outlined and implemented by the dietitians along with multidisciplinary team.

The effects of implementation of a stepwise algorithmic protocol for nutrition care process in gastro-intestinal surgical children in Pediatric Intensive Care Unit (PICU)

INTRODUCTION

Malnutrition is known as one of the major health problems among critically ill children; optimum nutrition support is considered as a therapeutic strategy to improve clinical outcomes and minimize the length of Pediatric Intensive Care Unit (PICU) staying as well as its costs. Implementation of an algorithmic protocol can result in the upgrade of the quality of nutrition support system in PICU.

METHOD

In this study, we developed a stepwise algorithmic nutrition care protocol for PICU patients in two phases as follows: a critical review of past literature and an expert discussion panel. The final structured protocol includes three following steps for the nutrition care process: 1) Initial nutrition screening and assessment, 2) Nutritional intervention and 3) Nutritional monitoring. Pre and post-implementation audits were carried out in a 23 bed medical/surgical PICU in a children's hospital affiliated to Mashhad University of Medical Sciences over two 4-week periods to evaluate the impact of the algorithm implementation. The post-implementation audit was performed by passing 12 weeks from the protocol implementation. Critically ill children aged between 1month and 10 years, and PICU length of stay>24 h who were in post gastrointestinal surgery state, were enrolled.

RESULTS

Totally, 34 eligible critically ill gastrointestinal surgical children in post-implementation audit were compared with 30 patients with similar eligibility criteria in the pre-implementation audit. Notably, there were no significant differences in gender, median age, length of PICU stay, and mechanical ventilation requirement in the two audits. The comparison of our pre and post-implementation audits showed a significant increase in the proportion of energy delivery goal achievement following performing our intervention (56.7%, and 85.3%, for pre and post-implementation audits, respectively; p-value = 0.01).Additionally, time of achieving energy and protein goals were significantly decreased (5.5 vs. 3 days; p-value = 0.008 and 4 vs 3 days; p-value = 0.002, for energy and protein delivery goal achievements, respectively).

CONCLUSION

The implementation of the algorithm have significantly improved the adequacy ratio of energy delivery and also decreased the time to achieve the goal in energy and protein intake among critically ill children in post-gastrointestinal state. In this regard, further prospective studies are needed for continuing the evaluation of the algorithm implementation outcomes in critically ill children with different surgical and internal underlying diseases.

Translation and adaptation of the modified NUTRIC score for critically ill patients

BACKGROUND & AIMS

Some critically ill patients are at high nutritional risk, and early identification of these patients is needed to reduce morbidity and mortality related to underfeeding. The Modified NUTrition Risk in Critically ill (mNUTRIC) score is the first nutritional risk assessment tool developed and validated specifically for ICU patients. This study aims to translate and adapt the Modified NUTRIC (mNUTRIC) Score into Persian to facilitate use in Iranian Intensive Care Units and assess its efficiency in a pilot sample.

METHOD

The translation process followed standardized steps: initial translation, synthesis of translations, back -translation to the English language, revision and cultural adaptation of the tool by language specialist and expert committee. A pilot study was conducted on the application of the tool in 46 critically ill patients from three ICUs in Iran hospitals.

RESULTS

The translation and adaptation process generated a feasible version of the mNUTRIC Score in the Persian language.The translated version was easily introduced into Iranian ICUs. The prevalence of patients with a mNUTRIC score of five or more was 43% (n = 46).

CONCLUSION

Translation of mNUTRIC Score from English into Persian, following internationally accepted methodology, has provided the ICU care in Iran with a comprehensive and useful instrument.

Utilization of indirect calorimetry to assist in determining undiagnosed hypothyroidism in a patient on mechanical ventilation

Published predictive equations are required when indirect calorimetry (IC) is unavailable in the clinical setting. Several medical conditions that are not accounted for by published predictive equations can impact a patient's resting energy expenditure, such as adrenal changes or alterations in thyroid-stimulating hormone (TSH). TSH levels significantly impact a patient's resting energy expenditure, with hypothyroidism decreasing and hyperthyroidism increasing energy requirements. Clinical hypothyroidism has been correlated with increased ventilator dependency in patients with critical illness and malnutrition. The following case study describes the utilization of IC to trigger a full evaluation for the diagnosis of hypothyroidism in an adult patient with multiple myeloma who was mechanically ventilated. IC results for this patient were 39% lower than estimated by predictive energy equations. TSH, thyroxine, and triiodothyronine serum assays were obtained to rule out hypothyroidism. Based on elevated TSH and low thyroxine, the patient was found to have undiagnosed hypothyroidism. Appropriate pharmaceutical and nutrition interventions were made based upon these results. This case demonstrates the impact hormonal changes can have on resting energy expenditure and how the utilization of IC can provide additional information other than energy requirements.

Fat-1 transgenic mice rich in endogenous omega-3 fatty acids are protected from lipopolysaccharide-induced cardiac dysfunction

Aims

Cardiac malfunctions developing in result of sepsis are hard to treat so they eventually contribute to the increased mortality. Previous reports indicated for therapeutic potential of exogenous ω‐3 polyunsaturated fatty acids (PUFA) in sepsis, but potential benefits of this compound on the malfunctional heart have not been explored yet. In the present study, we investigated whether the constantly elevated levels of endogenous ω‐3 PUFA in transgenic fat‐1 mice would alleviate the lipopolysaccharide (LPS)‐induced cardiac failure and death.

Methods and results

After both wild type (WT) and transgenic fat‐1 mice were challenged with LPS, a Kaplan–Meier curve and echocardiography were performed to evaluate the survival rates and cardiac function. Proteomics analysis, RT‐PCR, western blotting, immune‐histochemistry, and transmission electron microscopy were further performed to investigate the underlying mechanisms. Results showed that transgenic fat‐1 mice exhibited the significantly lower mortality after LPS challenge as compared with their WT counterparts (30% vs. 42.5%, P < 0.05). LPS injection consistently impaired the left ventricular contractile function and caused the cardiac injury in the wild type mice, but not significantly affected the fat‐1 mice (P < 0.05). Proteomic analyses, ELISA, and immunohistochemistry further revealed that myocardium of the LPS‐challenged fat‐1 mice demonstrated the significantly lower levels of pro‐inflammatory markers and ROS than WT mice. Meaningfully, the LPS‐treated fat‐1 mice also demonstrated a significantly higher levels of LC3 II/I and Atg7 expressions than the LPS‐treated WT mice (P < 0.05), as well as displayed a selectively increased levels of peroxisome proliferator‐activated receptor (PPAR) γ and sirtuin (Sirt)‐1 expression, associated with a parallel decrease in NFκB activation.

Conclusions

The fat‐1 mice were protected from the detrimental LPS‐induced inflammation and oxidative stress, and exhibited enhancement of the autophagic flux activities, associating with the increased Sirt‐1 and PPARγ signals.

Knowledge, attitudes, clinical practice and perceived barriers with nutrition support among physicians and nurses in the emergency department: A national cross-sectional survey

OBJECTIVE

To explore the current status of knowledge, attitudes, clinical practice and barriers in nutrition support amongst physicians and nurses working in Chinese Emergency Departments (EDs), and the relationship between their demographic characteristics and knowledge and attitudes regarding nutrition support.

METHODS

A 34 item survey was developed, validated and distributed nationally to ED physicians and nurses from 1st April to 1st May 2018.

RESULTS

A total of 1234 respondents completed and returned the survey. Knowledge of nutrition support was moderate (mean: 6.70/10) and differed significantly based on demographic characteristics (e.g. age, staff type). Attitudes was very positive (4.15/5), more so among nurses compared to physicians. Only few (5.6%) respondents reportedly assessed nutritional condition for all patients. The most common barriers to optimize nutrition support were being too busy, lack of standardized protocol specific to ED, and lack of teamwork and coordination.

CONCLUSION

In a subset of physicians and nurses working in Chinese EDs, limited knowledge but positive attitudes toward nutrition support was evident. Recommendations to optimize evidence-based nutritional support practice in the ED include initiating, implementing and sustaining training regarding nutrition support, establishing, implementing and evaluating a standardized protocol, and enhancing interdisciplinary coordination.

Trauma, a Matter of the Heart-Molecular Mechanism of Post-Traumatic Cardiac Dysfunction

Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called "commotio cordis" are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.

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

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.

Role of anabolic testosterone agents and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

ICU survivors frequently suffer significant, prolonged physical disability. 'ICU Survivorship', or addressing quality-of-life impairments post-ICU care, is a defining challenge, and existing standards of care fail to successfully address these disabilities. We suggest addressing persistent catabolism by treatment with testosterone analogues combined with structured exercise is a promising novel intervention to improve 'ICU Survivorship'.

RECENT FINDINGS

One explanation for lack of success in addressing post-ICU physical disability is most ICU patients exhibit severe testosterone deficiencies early in ICU that drives persistent catabolism despite rehabilitation efforts. Oxandrolone is an FDA-approved testosterone analogue for treating muscle weakness in ICU patients. A growing number of trials with this agent combined with structured exercise show clinical benefit, including improved physical function and safety in burns and other catabolic states. However, no trials of oxandrolone/testosterone and exercise in nonburn ICU populations have been conducted.

SUMMARY

Critical illness leads to a catabolic state, including severe testosterone deficiency that persists throughout hospital stay, and results in persistent muscle weakness and physical dysfunction. The combination of an anabolic agent with adequate nutrition and structured exercise is likely essential to optimize muscle mass/strength and physical function in ICU survivors. Further research in ICU populations is needed.

[Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study]

Introduction

Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed.

Review of evolution and current status of protein requirements and provision in acute illness and critical care

Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

Association Between Low Zinc Levels and Severity of Acute Respiratory Distress Syndrome by New Coronavirus SARS-CoV-2

BACKGROUND

We verify the prevalence of low zinc levels among critically ill patients infected by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in the intensive care unit (ICU) who required invasive mechanical ventilation, as well as its association with severity of acute respiratory distress syndrome (ARDS).

METHODS

This is an observational study composed of patients admitted to the ICU. Demographics, anthropometric data for calculating body mass index (BMI), and laboratory data were obtained at admission: blood count, ferritin, arterial blood gas, serum zinc levels, and C-reactive protein. Also, arterial oxygen tension (PaO₂ ) divided by fractional inspired oxygen (FiO₂ ) was calculated by the first arterial blood gas after intubation. A diagnosis of severe ARDS was determined if the PaO₂ /FiO₂ ratio was ≤100 mm Hg. Low zinc levels were established if zinc levels were <70 μg/dL.

RESULTS

A total of 269 patients met inclusion criteria; 51.3% were men; median age was 74 (66-81) years; 91.1% (245 of 269) were elderly. The median BMI was 30.1 (24.7-32.1) kg/m² , with 59.9% (161 of 269) of patients having overweight and obesity. The prevalence of low zinc levels was 79.6% (214 of 269) and severe ARDS was 56.5% (152 of 269). There was an association of low zinc levels and severe ARDS (odds ratio [OR], 14.4; 95% CI, 6.2-33.5; P < .001), even after adjusting for baseline variables (OR, 15.4; 95% CI, 6.5-36.3; P < .001).

CONCLUSION

Critically ill patients infected by SARS-CoV-2 with severe ARDS have a high prevalence of low serum zinc levels.

Comparison of Energy Expenditure in Mechanically Ventilated Septic Shock Patients in Acute and Recovery Periods via Indirect Calorimetry

BACKGROUND

Nutrition in intensive care units (ICUs) affects morbidity and mortality. We aimed to evaluate the energy expenditure of mechanically ventilated patients in early and late septic shock periods.

METHODS

This study retrospectively evaluated 28 mechanically ventilated septic shock patients (11 female/17 male) in a medical ICU. Indirect calorimetry (IC) measurement was performed for 24 hours during the acute and recovery periods of septic shock. The energy values calculated by Harris-Benedict equation (predicted resting energy expenditure [PREE]), measured by IC (measured resting energy expenditure [MREE]), and given to each patient were obtained in the acute and recovery periods.

RESULTS

The mean age was 67.46 ± 14.92 (36-91) years. The MREE was 2741.1 ± 706.3 kcal/d (38.61 ± 11.44 kcal/kg/d) and 2332.8 ± 426.6 kcal/d (32.65 ± 7.8 kcal/kg/d) in the acute and recovery periods, respectively, and showed significant differences (P = 0.001). The patients' energy intake was 1152.7 ± 207.1 kcal/d and 1542.7 ± 433.3 kcal/d in the acute and recovery periods, respectively. A significant difference existed between energy intake and MREE during the acute and recovery periods (P < 0.001 for both).

CONCLUSION

Our findings showed that energy expenditure increases in septic shock. Significant differences existed between MREE, PREE, and energy intake, which were not correlated. The MREE was higher in the acute period. Despite the increasing energy requirement, the PREE and energy intake were well below MREE. For better clinical outcomes, each patient's energy expenditure must be closely monitored and evaluated using intermittent IC measurements.

Ward-based nutrition care practices and a snapshot of patient care: Results from nutritionDay in the ICU

BACKGROUND

Poor adherence to intensive care unit (ICU) guidelines is common, leading to suboptimal nutritional care. This study determined current ward-based nutrition care practices in the Indian ICU setting, comparing them to international best-practice guidelines and provided patient demographic, clinical and nutritional information to serve as baseline data for future benchmarking.

METHODS

This multi-site cross-sectional retrospective study analysed data collected from nutritionDay worldwide audits (2012-2016) across ICUs from a chain of urban private hospitals in India. Additional guideline-specific data were collected through questionnaires and phone interviews with the Head of Dietetics Departments in the participating hospitals.

RESULTS

Overall, 10 ICUs and 457 participants were included. It was common practice to use modified versions of the Mini Nutritional Assessment-Short Form (MNA-SF) and Subjective Global Assessment (SGA) for nutrition screening and assessment. Nearly half the participants (n = 222, 49%) received nutrition orally. A majority of the remaining participants received enteral nutrition (n = 163, 36%) or no nutrition (n = 60, 13%) at the time of data collection. The calories prescribed for most participants were between 1500 and 1999 kilocalories per day (n = 207, 45%), with no nutrition planned for 115 (25%) participants. Three-quarters (n = 129, 74%) of participants on EN received the planned calories, while 24% (n = 42) were given less than planned.

CONCLUSION

Overall, most participants received the calories planned for enteral nutrition. The use of modified screening and assessment tools and suboptimal delivery of EN remains a global problem for critical care, possibly requiring a more pragmatic approach to nutritional therapy.

Assessment of Total Parenteral Nutrition administration among Intensive Care Unit patients at Omdurman Military Hospital, Sudan.. [DOI: 10.1101/2020.10.19.20215053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Total parenteral nutrition is one of the important types of nutrition among patients with intestinal failure. This research was intended to assess total parenteral nutrition administration of the intensive care unit patients at the Military hospital, Sudan. A cross-sectional hospital-based study assessed the patients records in the period between April 2014-November 2015, data were analyzed through chi-square test, it was considered significant when p≤ 0.05. Twenty patients who received total parenteral nutrition were assessed, 60% were males, while 40% were females. The most frequent indication for total parenteral nutrition was laparotomy (35% of patients). The duration of total parenteral nutrition was assessed, 70% of patients had duration between 1-20 days. Regarding total parenteral nutrition complications, the most frequent complication was hypokalemia (45% of patients), refeeding syndrome occurred in 10 % of patients. A statistically significant association was found between total parenteral nutrition duration when assessed with age and indication (p= 0.005 and 0.000 respectively). Patients suffering from electrolytes imbalance need more care to avoid the development of refeeding syndrome, as well as high level of hygiene is strictly required to overcome septic complications. There is a need to consider specialized care team composed of nurses, clinical pharmacists and nutritionists.

Pilot Study to Investigate Enteral Feeding Practices and the Incidence of Underfeeding Among Mechanically Ventilated Critically Ill Patients at a Specialist Tertiary Care Hospital in Saudi Arabia

BACKGROUND

Enteral nutrition (EN) is an essential therapeutic intervention. Many studies internationally have reviewed feeding practices in intensive care units (ICUs) and recorded the incidence of underfeeding in these settings, yet none were performed in the Middle East, including Saudi Arabia. The purpose of the study is to assess the adequacy of EN delivery and investigate the enteral feeding practices in the ICU at a specialized tertiary care hospital in Saudi Arabia.

METHODS

In this observational study, we prospectively monitored energy and protein delivery for 6 consecutive days in critically ill patients. Malnutrition was assessed by Nutrition Risk Screening (NRS-2002) scores. Underfeeding was identified by comparing the intake against the calculated requirements. Patients were categorized into early and late EN starters to investigate whether the time of EN initiation impacts the cumulative nutrition intake.

RESULTS

This study included 43 patients. About 44% (19 of 43) of the patients were malnourished on admission to ICU, and the prevalence of underfeeding was >90%. The median cumulative intake of energy and protein was 39% and 31% of the estimated requirements, respectively. Patients who started early EN had statistically higher cumulative energy and protein intake (P-value = .00). Patients treated with inotropes received less energy and protein compared with those who did not receive inotropes (P-value = .00). Higher NRS-2002 score was associated with fewer ventilation-free hours (r = -0.369, P-value = .045).

CONCLUSION

Protein underfeeding remains a significant problem in ICU settings. The time of EN initiation plays a major role in determining when the nutrition requirements will be met. Therefore, it is crucial to implement effective feeding protocols to ensure early initiation of EN when permissible.

First international meeting of early career investigators: Current opportunities, challenges and horizon in critical care nutrition research

BACKGROUND

Appropriate nutritional support is a key component of care for critically ill patients. While malnutrition increases complications, impacting long term outcomes and healthcare-related costs, uncertainties persist regarding optimal provision of nutritional support in this setting.

METHODS

An international group of healthcare providers (HCPs) from critical care specialties and nutrition researchers convened to identify knowledge gaps and learnings from studies in critical care nutrition. Clinical research needs were identified in order to better inform future nutrition practices.

RESULTS

Challenges in critical care nutrition arise, in part, from inconsistent outcomes in several large-scale studies regarding the optimal amount of calories and protein to prescribe, the optimal time to initiate nutritional support and the role of parental nutrition to support critically ill patients. Furthermore, there is uncertainty on how best to identify patients at nutritional risk, and the appropriate outcome measures for ICU nutrition studies. Given HCPs have a suboptimal evidence base to inform the nutritional management of critically ill patients, further well-designed clinical trials capturing clinically relevant endpoints are needed to address these knowledge gaps.

CONCLUSIONS

The identified aspects for future research could be addressed in studies designed and conducted in collaboration with an international team of interdisciplinary nutrition experts. The aim of this collaboration is to address the unmet need for robust clinical data needed to develop high-quality evidence-based nutritional intervention recommendations to better inform the future management of critically ill patients.

Incidence and risk factors of carbapenem-resistant Enterobacteriaceae infection in intensive care units: a matched case-control study

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) infection is associated with intensive care admissions, morbidity, and mortality. Our study aimed to determine the incidence, risk factors, and patient outcomes of CRE in the ICU units.

METHODS

This was a retrospective matched case-control study of patients admitted to ICUs. Patients who have positive cultures of CRE and carbapenem-susceptible Enterobacteriaceae (CSE) were included in the study. Patients were randomly selected from a pool of CSE subjects in a ratio of 1:1 of CRE to CSE as control patients.

RESULTS

The infection rate with CRE among all patients admitted to ICUs was 7.6% and the incidence of CRE infection was 5.6 per 1,000 person-day. The risk factors independently associated with CRE infection were: Higher Sequential Organ Failure Assessment (SOFA) and Nutrition Risk in Critically ill (NUTRIC) scores, prolonged ICU length of stay (LOS), previous surgery, dialysis and mechanical ventilation during ICU stay, and previous use of aminoglycoside and carbapenems.

CONCLUSION

In this retrospective study, the incidence of CRE infection was relatively elevated in patients admitted to ICU. Patients with high SOFA and NUTRIC scores, prolonged ICU LOS, previous surgery, dialysis and mechanical ventilation, and prior aminoglycosides and carbapenems use, may have an increased risk of CRE infection.

Nutritional Support of the Critically Ill Small Animal Patient

Over the past couple of decades, a component of veterinary critical care was simply to ensure that nutritional support formed some part of the treatment plan. Great emphasis was made on early placement of feeding tubes in critically ill veterinary patients to facilitate enteral feeding. Progress has been made on techniques for nutritional provision, establishing feasibility of nutritional interventions in various patient populations and establishing that nutritional support does have an important role in veterinary critical care. Some refinement of appropriate caloric targets in critically ill animals has decreased complications relating to overfeeding, but further work is required to establish optimal feeding regimes.

[Nutritional management of the critically ill inpatient with COVID-19. A narrative review]

Introduction

The current COVID-19 pandemic mainly affects older people, those with obesity or other coexisting chronic diseases such as type-2 diabetes and high blood pressure. It has been observed that about 20 % of patients will require hospitalization, and some of them will need the support of invasive mechanical ventilation in intensive care units. Nutritional status appears to be a relevant factor influencing the clinical outcome of critically ill patients with COVID-19. Several international guidelines have provided recommendations to ensure energy and protein intake in people with COVID-19, with safety measures to reduce the risk of infection in healthcare personnel. The purpose of this review is to analyze the main recommendations related to adequate nutritional management for critically ill patients with COVID-19 in order to improve their prognosis and clinical outcomes.

Refeeding Hypophosphatemia in Patients Receiving Parenteral Nutrition: Prevalence, Risk Factors, and Predicting Its Occurrence

BACKGROUND

Patients receiving parenteral nutrition (PN) support may develop refeeding hypophosphatemia (RH), and its prevalence is highly variable in the literature. Identifying at-risk patients is crucial to minimize clinical complications. The National Institute for Health and Clinical Excellence (NICE) guidelines are used widely to assess the risk of RH, but they lack validation. We aim to (1) identify the prevalence of RH by multiple diagnostic criteria; (2) assess the predictive ability of the NICE guidelines for RH; and (3) identify important risk factors for RH and evaluate their predictive abilities for RH in a new model.

METHODS

This is a single-center retrospective study on adult patients with PN ≥48 hours. Prevalence of RH was determined by 4 established diagnostic criteria. Prognostic accuracy of the NICE guidelines were assessed by the area under the receiver operating characteristic (ROC) curve. Multivariable logistic regressions were performed to develop a new risk-assessment model.

RESULTS

Of 149 enrolled patients, 23%-48% (35 to 72 of 149 patients) developed RH (depending on the diagnostic criteria used). The NICE guidelines demonstrated poor discrimination across all diagnostic criteria (ROC, 0.43-0.53). Critical illness, the use of diuretics, and hypomagnesemia prior to PN were independently associated with RH. These risk factors formed the new model for predicting RH and had good discrimination (ROC 0.74; 95% confidence interval, 0.66-0.82).

CONCLUSION

Prevalence of RH varied according to established diagnostic criteria. The current NICE guidelines poorly predict the occurrence of RH, and modification is likely beneficial. A new risk-assessment model was developed; nevertheless, further validation is required.

Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.

NUTRIC and Modified NUTRIC are Accurate Predictors of Outcome in End-Stage Liver Disease: A Validation in Critically Ill Patients with Liver Cirrhosis

Malnutrition in critically ill patients with cirrhosis is a frequent but often overlooked complication with high prognostic relevance. The Nutrition Risk in Critically ill (NUTRIC) score and its modified variant (mNUTRIC) were established to assess the nutrition risk of intensive care unit patients. Considering the high mortality of cirrhosis in critically ill patients, this study aims to evaluate the discriminative ability of NUTRIC and mNUTRIC to predict outcome. We performed a retro-prospective evaluation in 150 Caucasian cirrhotic patients admitted to our ICU. Comparative prognostic analyses between NUTRIC and mNUTRIC were assessed in 114 patients. On ICU admission, a large proportion of 65% were classified as high NUTRIC (6-10) and 75% were categorized as high mNUTRIC (5-9). High nutritional risk was linked to disease severity and poor outcome. NUTRIC was moderately superior to mNUTRIC in prediction of 28-day mortality (area under curve 0.806 vs. 0.788) as well as 3-month mortality (area under curve 0.839 vs. 0.819). We found a significant association of NUTRIC and mNUTRIC with MELD, CHILD, renal function, interleukin 6 and albumin, but not with body mass index. NUTRIC and mNUTRIC are characterized by high prognostic accuracy in critically ill patients with cirrhosis. NUTRIC revealed a moderate advantage in prognostic ability compared to mNUTRIC.

Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial

While medical nutrition therapy is an essential part of the care for critically ill patients, uncertainty exists about the right form, dosage, timing and route in relation to the phases of critical illness. As enteral nutrition (EN) is often withheld or interrupted during the intensive care unit (ICU) stay, combined EN and parenteral nutrition (PN) may represent an effective and safe option to achieve energy and protein goals as recommended by international guidelines. We hypothesise that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the ICU. Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching energy and protein goals in patients at high nutritional risk, while avoiding overfeeding. This approach will be tested in the here-presented EFFORTcombo trial. Nutritionally high-risk ICU patients will be randomised to either high (≥2·2 g/kg per d) or low protein (≤1·2 g/kg per d). In the high protein group, the patients will receive EN+PN; in the low protein group, patients will be given EN alone. EN will be started in accordance with international guidelines in both groups. Efforts will be made to reach nutrition goals within 48-96 h. The efficacy of the proposed nutritional strategy will be tested as an innovative approach by functional outcomes at ICU and hospital discharge, as well as at a 6-month follow-up.

Calorie provision from citrate anticoagulation in continuous renal replacement therapy in critical care

Background

Citrate is used as a regional anticoagulant for continuous veno-venous haemofiltration and provides 0.59 kcal/mmol. Previous studies hypothesised continuous veno-venous haemofiltration can provide 200-1300 kcal/day dependent on the anticoagulant and replacement solutions used. The aim of this study was to calculate the calorie load from citrate in our patient group.

Methods

An equation derived from a paper by Oudemans-van Straaten was used to estimate calorie provision from citrate. Citrate calorie load was defined as the difference between the citrate in the filter circuit and the removal by continuous veno-venous haemofiltration. Clinical data were recorded on 20 consecutive patients admitted to intensive care unit and commenced on citrate continuous veno-venous haemofiltration using prismacitrate 18/0 by Gambro, a tri-sodium citrate solution. Clinical data recorded included patient demographics, filter settings including blood flow, filtration factor, citrate dose and time on filtration daily.

Results

A total of 20 critically ill patients received continuous veno-venous haemofiltration for treatment of a new acute kidney injury, mean age 66 years, 65% male. Mean duration of continuous veno-venous haemofiltration was 3.7 days. Mean daily time on filtration was 20 h/day. Mean filtration fraction, citrate dose and blood flow were 30%, 3 mmol/L and 123 ml/min, respectively. Our calculation showed that a mean of 9.5 ± 1.7 cal/h were provided from citrate with a mean daily calorie load of 196 ± 69 kcal.

Conclusions

Continuous veno-venous haemofiltration with tri-sodium citrate provided an additional 196 ± 69 kcal/day. The calorie load from citrate continuous veno-venous haemofiltration should be calculated regularly as changes in filter settings, in particular citrate dose and blood flow can have a significant impact on calorie provision.

Nutritional adequacy in critically ill patients: Result of PNSI study

BACKGROUND & AIMS

Critically ill patients are provided with the intensive care medicine to prevent further complications, including malnutrition, disease progression, and even death. This study was intended to assess nutritional support and its' efficacy in the Intensive Care Units (ICUs) of Iran.

METHODS

This cross-sectional study assessed 50 ICU's patients out of 25 hospitals in the 10 major regions of Iran's health system and was performed using the multistage cluster sampling design. The data were collected from patient's medical records, ICU nursing sheets, patients or their relatives from 2017 to 2018. Nutritional status was investigated by modified NUTRIC score and food frequency checklist.

RESULTS

This study included 1321 ICU patients with the mean age of 54.8 ± 19.97 years, mean mNUTRIC score of 3.4 ± 2.14, and malnutrition rate of 32.6%. The mean time of first feeding was the second day and most of patients (66%) received nutrition support, mainly through enteral (57.2%) or oral (37%) route during ICU stay. The patients received 59.2 ± 37.78 percent of required calorie and 55.5 ± 30.04 percent of required protein. Adequate intake of energy and protein was provided for 16.2% and 10.7% of the patients, respectively. The result of regression analysis showed that the odds ratio of mNUTRIC score was 0.85 (95% confidence interval [CI] = 0.74-0.98) and APACHE II was 0.92 (95%CI = 0.89-0.95) for the prediction of energy deficiency. Nutrition intake was significantly different from patient's nutritional requirements both in terms of energy (p < 0.001) and protein (p < 0.001). Also, mean mNUTRIC score varied notably (p = 0.011) with changing in energy intake, defined as underfeeding, adequate feeding, and overfeeding.

CONCLUSION

The present findings shown that, provided nutritional care for ICU patients is not adequate for their requirements and nutritional status.

The modified NUTRIC score can be used for nutritional risk assessment as well as prognosis prediction in critically ill COVID-19 patients

Background & aims

In the newly emerged Coronavirus Disease 2019 (COVID-19) disaster, little is known about the nutritional risks for critically ill patients. It is also unknown whether the modified Nutrition Risk in the Critically ill (mNUTRIC) score is applicable for nutritional risk assessment in intensive care unit (ICU) COVID-19 patients. We set out to investigate the applicability of the mNUTRIC score for assessing nutritional risks and predicting outcomes for these critically ill COVID-19 patients.

Methods

This retrospective observational study was conducted in three ICUs which had been specially established and equipped for COVID-19 in Wuhan, China. The study population was critically ill COVID-19 patients who had been admitted to these ICUs between January 28 and February 21, 2020. Exclusion criteria were as follows: 1) patients of ＜18 years; 2) patients who were pregnant; 3) length of ICU stay of ＜24 h; 4) insufficient medical information available. Patients' characteristics and clinical information were obtained from electronic medical and nursing records. The nutritional risk for each patient was assessed at their ICU admission using the mNUTRIC score. A score of ≥5 indicated high nutritional risk. Mortality was calculated according to patients’ outcomes following 28 days of hospitalization in ICU.

Results

A total of 136 critically ill COVID-19 patients with a median age of 69 years (IQR: 57–77), 86 (63%) males and 50 (37%) females, were included in the study. Based on the mNUTRIC score at ICU admission, a high nutritional risk (≥5 points) was observed in 61% of the critically ill COVID-19 patients, while a low nutritional risk (<5 points) was observed in 39%. The mortality of ICU 28-day was significantly higher in the high nutritional risk group than in the low nutritional risk group (87% vs 49%, P ＜0.001). Patients in the high nutritional risk group exhibited significantly higher incidences of acute respiratory distress syndrome, acute myocardial injury, secondary infection, shock and use of vasopressors. Additionally, use of a multivariate Cox analysis showed that patients with high nutritional risk had a higher probability of death at ICU 28-day than those with low nutritional risk (adjusted HR = 2.01, 95% CI: 1.22–3.32, P = 0.006).

Conclusions

A large proportion of critically ill COVID-19 patients had a high nutritional risk, as revealed by their mNUTRIC score. Patients with high nutritional risk at ICU admission exhibited significantly higher mortality of ICU 28-day, as well as twice the probability of death at ICU 28-day than those with low nutritional risk. Therefore, the mNUTRIC score may be an appropriate tool for nutritional risk assessment and prognosis prediction for critically ill COVID-19 patients.

Validation of the modified NUTRIC score on critically ill Jordanian patients: A retrospective study

BACKGROUND

Nutritional status has been proven to be associated with poor outcomes in mechanically ventilated patients in intensive care units (ICU). Nutritional assessment has been assessed using different tools. Few data are available on the validity of the modified Nutrition Risk Assessment Tool for Critically Ill (mNUTRIC) score in ICU patients receiving mechanical ventilation (MV).

AIM

This study aimed to assess prognostic performance of the mNUTRIC score for discriminative abilities for 30-day mortality and prolonged MV.

METHODS

This was a multi-centre retrospective study that included 737 mechanically ventilated patients using secondary data analysis. Data were collected on variables required to calculate mNUTRIC score. Patients with a mNUTRIC score ≥5 were considered at nutritional risk. Predictive performance of the mNUTRIC was assessed for discriminative abilities for Acute Physiology and Chronic Health Evaluation II at baseline, mortality in 42 days of follow-up and outcomes related to MV.

RESULTS

A total of 737 patients on MV met the inclusion criteria. The majority (57.1%) of patients were male. The mean age of the participants was 62.1±18 years. Of all patients, 482 (58%) were at high nutritional risk (mNUTRIC score ≥5). Median ventilator days were 3 (±7.2) days and 72 (±174) hours. The overall mortality rate was 78.8% (n=652), and weaning failure was 79.8% (n=660).

CONCLUSIONS

This study showed new evidence on the validity of the mNUTRIC as a tool for assessing nutritional risk in an ICU population in Jordan. The mNUTRIC score obtained from the current retrospective data suggests that the use of the tool can truly identify and diagnose critically ill patients with malnutrition.

Comparison of Measured Energy Expenditure Using Indirect Calorimetry vs Predictive Equations for Liver Transplant Recipients

BACKGROUND

To assess the appropriate energy expenditure requirement for liver transplant (LT) recipients in South Korea, 4 commonly used predictive equations were compared with indirect calorimetry (IC).

METHODS

A prospective observational study was conducted in the surgical intensive care unit (ICU) of an academic tertiary hospital between December 2017 and September 2018. The study population comprised LT recipients expected to remain in the ICU >48 hours postoperatively. Resting energy expenditure (REE) was measured 48 hours after ICU admission using open-circuit IC. Theoretical REE was estimated using 4 predictive equations (simple weight-based equation [25 kcal/kg/day], Harris-Benedict, Ireton-Jones [ventilated], and Penn State 1988). Derived and measured REE values were compared using an intraclass correlation coefficient (ICC) and Bland-Altman plots.

RESULTS

Of 50 patients screened, 46 were enrolled, were measured, and completed the study. The Penn State equation showed 65.0% agreement with IC (ICC, 0.65); the simple weight-based (25 kcal/kg/day), Harris-Benedict, and Ireton-Jones equations showed 62.0%, 56.0% and 39.0% agreement, respectively. Bland-Altman analysis showed that all 4 predictive equations had fixed bias, although the simple weight-based equation (25 kcal/kg/day) showed the least.

CONCLUSION

Although predicted REE calculated using the Penn State method agreed with the measured REE, all 4 equations showed fixed bias and appeared to be inaccurate for predicting REE in LT recipients. Precise measurement using IC may be necessary when treating LT recipients to avoid underestimating or overestimating their metabolic needs.

Geometric framework reveals that a moderate protein, high carbohydrate intake is optimal for severe burn injury in mice

Nutritional therapy is a cornerstone of burns management. The optimal macronutrient intake for wound healing after burn injury has not been identified, although high-energy, high-protein diets are favoured. The present study aimed to identify the optimal macronutrient intake for burn wound healing. The geometric framework (GF) was used to analyse wound healing after a 10 % total body surface area contact burn in mice ad libitum fed one of the eleven high-energy diets, varying in macronutrient composition with protein (P5-60 %), carbohydrate (C20-75 %) and fat (F20-75 %). In the GF study, the optimal ratio for wound healing was identified as a moderate-protein, high-carbohydrate diet with a protein:carbohydrate:fat (P:C:F) ratio of 1:4:2. High carbohydrate intake was associated with lower mortality, improved body weight and a beneficial pattern of body fat reserves. Protein intake was essential to prevent weight loss and mortality, but a protein intake target of about 7 kJ/d (about 15 % of energy intake) was identified, above which no further benefit was gained. High protein intake was associated with delayed wound healing and increased liver and spleen weight. As the GF study demonstrated that an initial very high protein intake prevented mortality, a very high-protein, moderate-carbohydrate diet (P40:C42:F18) was specifically designed. The dynamic diet study was also designed to combine and validate the benefits of an initial very high protein intake for mortality, and subsequent moderate protein, high carbohydrate intake for optimal wound healing. The dynamic feeding experiment showed switching from an initial very high-protein diet to the optimal moderate-protein, high-carbohydrate diet accelerated wound healing whilst preventing mortality and liver enlargement.

Nutritional therapy and outcomes in underweight critically ill patients

BACKGROUND & AIMS

Critically ill patients with body mass index (BMI) < 20 kg/m² have worse outcomes than normal/overweight patients possibly because underweight is a marker of malnutrition. To assess the effects of nutrition therapy in this population during the first week of an ICU stay.

METHODS

Prospective, 2-centre, observational study. Nutritional evaluations were performed between days 2 and 3 (first) and between days 5 and 7 (second) of ICU admission. In the first evaluation, patients were divided into non-fed (without nutritional support) and early-fed (those already receiving nutritional support) groups. In the second evaluation, patients were divided according to caloric intake (≥or<20 kcal/kg) and protein intake (≥or<1.3 g of protein/kg).

RESULTS

Of the 4236 patients screened and 342 were included in the cohort. Mortality was 58.5% (median 21 [11-38.25] days of follow-up). Unadjusted patient survival was worse in the non-fed group than in the early-fed group (HR 1.66; 95%CI, 1.18 to 2.32). There was no difference in mortality between groups after adjusting for the SOFA score on the day of the evaluation. At the second evaluation, unadjusted analysis showed better in-hospital survival in patients with higher caloric (HR0.58; 95%CI, 0.40 to 0.86) and protein intake (HR0.59; 95%CI, 0.42 to 0.82); there was no association between mortality and caloric or protein intake after adjusting for the SOFA score on the day of the evaluation.

CONCLUSION

Nutritional therapy in the first week of ICU stay did not affect vital outcome after adjusting for the SOFA score on the day of the evaluation in underweight critically ill patients.

CLINICAL TRIAL REGISTRY

ClinicalTrials.gov number NCT03398343.

Is slower advancement of enteral feeding superior to aggressive full feeding regimens in the early phase of critical illness

PURPOSE OF REVIEW

An excessive caloric intake during the acute phase of critical illness is associated with adverse effects, presumably related to overfeeding, inhibition of autophagy and refeeding syndrome. The purpose of this review is to summarize recently published clinical evidence in this area.

RECENT FINDINGS

Several observational studies, a few interventional trials, and systematic reviews/metaanalyses were published in 2017-2019. Most observational studies reported an association between caloric intakes below 70% of energy expenditure and a better vital outcome. In interventional trials, or systematic reviews, neither a benefit nor a harm was related to increases or decreases in caloric intake. Gastrointestinal dysfunction can be worsened by forced enteral feeding, whereas the absorption of nutrients can be impaired.

SUMMARY

Owing to the risks of the delivery of an excessive caloric intake, a strategy of permissive underfeeding implying a caloric intake matching a maximum of 70% of energy expenditure provides the best risk-to-benefit ratio during the acute phase of critical illness.

The epidemiology of overfeeding in mechanically ventilated intensive care patients

BACKGROUND AND AIMS

Nutrition research in the Intensive Care Unit (ICU) typically focusses on the epidemiology of underfeeding, particularly early in the ICU admission. Once the acute phase of critical illness has resolved, patients may be at risk of overfeeding. We assessed for the frequency and consequences of potential overfeeding in ICU patients mechanically ventilated (MV) for at least 10 days.

METHODS

Retrospective analysis of 105 MV patients including caloric input, estimated caloric requirements using the Schofield equation, and association between caloric input and several pre-defined clinical outcomes. To increase likelihood of detecting overfeeding, we conducted a post-hoc sensitivity analysis for sub-groups of patients who received on average < 25 kcal/kg/day (N = 55) and >30 kcal/kg/day (N = 17) between day 7-10 and performed repeat ANOVA.

RESULTS

There were no differences in the pre-defined outcomes for those given over, and below 25 kcal/kg/day. On each study day, approximately 25% of patients received >30 kcal/kg/day. Higher caloric delivery was statistically associated with increased minute ventilation on each study day (Spearman Rho approx 0.27;p ≤ 0.007) and also in sub-group analysis (p< 0.001). Higher caloric delivery was also associated with more frequent diarrhoea (p= 0.02) and greater insulin requirement. However, these differences did not translate into increased duration of mechanical ventilation, length of stay, or increased mortality. Higher caloric intake was less strongly associated with serum urea and creatinine, but not associated with agitation, abnormal liver function tests, fever, or antibiotic prescription.

CONCLUSIONS

Delivery of more than 25 kcal/kg/day was not associated with adverse outcomes. On post-hoc analysis, delivery of more than 30 kcal/kg/day was associated with increased minute ventilation, diarrhoea and insulin requirements but no differences in length of ventilation or in-hospital mortality.

Adjusted tight control blood glucose management in diabetic patients undergoing on pump coronary artery bypass graft. A randomized clinical trial

Background

Many of the patients who are undergoing Coronary Artery Bypass Graft have diabetes mellitus or metabolic syndrome and are at risk for hyperglycemia events.

Objective

The present study aimed to compare conventional glucose control with adjusted tight control in patients undergoing on-pump CABG.

Methods

This double -blind randomized clinical trial study was conducted in Shiraz, Iran, from September 2017-March 2018. Two consecutive groups of 75 patients undergoing elective on- pump coronary artery bypass graft surgery.

Intervention

The patients were divided into adjusted tight control of the blood glucose between 100 and 120 mg/dl and conventional method that the blood glucose maintained ≤200 mg/dl.

Primary outcomes were

mortality, sternal wound infection, cardiac arrhythmia, cerebrovascular attack, and acute renal failure.

Secondary outcomes included

duration of mechanical ventilation and length of ICU staying. The same main outcomes were evaluated after one month.

Statistical analysis

The data were analyzed using SPSS version 20(SPSS, Chicago, IL). Group comparisons were performed using t-tests and Chi-square tests. Repeated measurement test was used for comparing blood glucose in two groups. Mann Whitney U test was compared duration of the mechanical ventilation and length of ICU staying. Statistical significance was defined as a p value <0.05.

Results

There were no significant differences between main and secondary outcomes. About late outcomes, sternal wound infection was in the control group (7 patients) more than intervention (1 patient) (P < 0.05). No differences between other complications in both groups were observed. The occurrence of hypoglycemia was low in both groups. Hypokalemia was significantly higher in the intervention than in control (P < 0.001).

Conclusions

The findings showed using adjusted tight glycemic control to a level that is nearby to normal values during cardiac surgery may reduce episodes of hypoglycemia and thus reduces its side effects. As well as reduce hyperglycemic complications such as sternal wound infection.

Trial registration number

IRCT2013041713052N1). 2013-07-09.

Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

Protein intake and outcome in critically ill patients

PURPOSE OF REVIEW

The objective of this review is to describe the impact of protein intake on the outcomes of critically ill patients in the literature published in the preceding 2 years.

RECENT FINDINGS

Observational studies showed inconsistent results regarding the association of higher protein intake and outcomes of critically ill patients. Randomized controlled trials that directly compared higher versus lower protein intake in ICU patients are scarce, varied considerably in their designs and primary outcomes, and generally had relatively small differences in the amount of delivered protein between the study arms. Systematic reviews of existing studies showed no difference in mortality with higher protein intake. In addition, there is uncertainty regarding high protein provision in the early phase of critical illness.

SUMMARY

The optimal amount of protein intake in critically ill patients remains largely unclear and is considered a high priority for research. Ongoing clinical trials are likely to provide additional evidence on several important questions including the dose, timing, type of protein and the interaction with caloric intake and exercise.

Refeeding syndrome is associated with increased mortality in malnourished medical inpatients: Secondary analysis of a randomized trial

BACKGROUND

Whether the occurrence of refeeding syndrome (RFS), a metabolic condition characterized by electrolyte shifts after initiation of nutritional therapy, has a negative impact on clinical outcomes remains ill-defined. We prospectively investigated a subgroup of patients included in a multicentre, nutritional trial (EFFORT) for the occurrence of RFS.

METHODS

In this secondary analysis of a randomized-controlled trial investigating the effects of nutritional support in malnourished medical inpatients, we prospectively screened patients for RFS and classified them as "RFS confirmed" and "RFS not confirmed" based on predefined criteria (i.e. electrolyte shifts, clinical symptoms, clinical context, and patient history). We assessed associations of RFS and mortality within 180 days (primary endpoint) and other secondary endpoints using multivariable regression analysis.

RESULTS

Among 967 included patients, RFS was confirmed in 141 (14.6%) patients. Compared to patients with no evidence for RFS, patients with confirmed RFS had significantly increased 180-days mortality rates (42/141 (29.8%) vs 181/826 (21.9%), adjusted odds ratio (OR) 1.53 (95% CI 1.02 to 2.29), P < .05). Patients with RFS also had an increased risk for ICU admission (6/141 (4.3%) vs 13/826 (1.6%), adjusted OR 2.71 (95% CI 1.01 to 7.27), P < .05) and longer mean length of hospital stays (10.5 ± 6.9 vs 9.0 ± 6.6 days, adjusted difference 1.57 days (95% CI 0.38-2.75), P = .01).

CONCLUSION

A relevant proportion of medical inpatients with malnutrition develop features of RFS upon hospital admission, which is associated with long-term mortality and other adverse clinical outcomes. Further studies are needed to develop preventive strategies for RFS in this patient population.

The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial

BACKGROUND

The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in critically ill patients was safe and associated with major reduction in RRT initiation compared with an early strategy. The five criteria which mandated RRT initiation in the delayed arm were: severe hyperkalemia, severe acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia, serum urea concentration > 40 mmol/l and oliguria/anuria > 72 h. However, duration of anuria/oliguria and level of blood urea are still criteria open to debate. The objective of the study is to compare the delayed strategy used in AKIKI (now termed "standard") with another in which RRT is further delayed for a longer period (termed "delayed strategy").

METHODS/DESIGN

This is a prospective, multicenter, open-label, two-arm randomized trial. The study is composed of two stages (observational and randomization stages). At any time, the occurrence of a potentially severe condition (severe hyperkalemia, severe metabolic or mixed acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia) suggests immediate RRT initiation. Patients receiving (or who have received) intravenously administered catecholamines and/or invasive mechanical ventilation and presenting with AKI stage 3 of the KDIGO classification and with no potentially severe condition are included in the observational stage. Patients presenting a serum urea concentration > 40 mmol/l and/or an oliguria/anuria for more than 72 h are randomly allocated to a standard (RRT is initiated within 12 h) or a delayed RRT strategy (RRT is initiated only if an above-mentioned potentially severe condition occurs or if the serum urea concentration reaches 50 mmol/l). The primary outcome will be the number of RRT-free days at day 28. One interim analysis is planned. It is expected to include 810 patients in the observational stage and to randomize 270 subjects.

DISCUSSION

The AKIKI2 study should improve the knowledge of RRT initiation criteria in critically ill patients. The potential reduction in RRT use allowed by a delayed RRT strategy might be associated with less invasive care and decreased costs. Enrollment is ongoing. Inclusions are expected to be completed by November 2019.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03396757. Registered on 11 January 2018.

Management of Refeeding Syndrome in Medical Inpatients

Refeeding syndrome (RFS) is the metabolic response to the switch from starvation to a fed state in the initial phase of nutritional therapy in patients who are severely malnourished or metabolically stressed due to severe illness. It is characterized by increased serum glucose, electrolyte disturbances (particularly hypophosphatemia, hypokalemia, and hypomagnesemia), vitamin depletion (especially vitamin B1 thiamine), fluid imbalance, and salt retention, with resulting impaired organ function and cardiac arrhythmias. The awareness of the medical and nursing staff is often too low in clinical practice, leading to under-diagnosis of this complication, which often has an unspecific clinical presentation. This review provides important insights into the RFS, practical recommendations for the management of RFS in the medical inpatient population (excluding eating disorders) based on consensus opinion and on current evidence from clinical studies, including risk stratification, prevention, diagnosis, and management and monitoring of nutritional and fluid therapy.

Clinical Nutrition of Critically Ill Patients in the Context of the Latest ESPEN Guidelines

The group of patients most frequently in need of nutritional support are intensive care patients. This year (i.e., 2019), new European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines of clinical nutrition in intensive care were published, updating and gathering current knowledge on the subject of this group of patients. Planning the right nutritional intervention is often a challenging task involving the necessity of the choice of the enteral nutrition (EN) or parenteral nutrition (PN) route of administration, time of initiation, energy demand, amino acid content and demand as well as the use of immunomodulatory nutrition. The aim of this study was to specify and discuss the basic aspects of the clinical nutrition of critically ill patients recommended by ESPEN guidelines. Clinical nutrition in intensive care seems to be the best-studied type of nutritional intervention. However, meta-analyses and clinical studies comparing EN and PN and their impact on the prognosis of the intensive care patients showed ambiguous results. The nutritional interventions, starting with EN, should be initiated within 24-48 h whereas PN, if recommended, should be implemented within 3-7 days. The recommended method of calculation of the energy demand is indirect calorimetry, however, there are also validated equations used worldwide in everyday practice. The recommended protein intake in this group of patients and the results of insufficient or too high supply was addressed. In light of the concept of immunomodulatory nutrition, the use of appropriate amino acid solutions and lipid emulsion that can bring a positive effect on the modulation of the immune response was discussed.

[Effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis]

OBJECTIVES

To compare the effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults, and to investigate the influence of protein intake upon the outcome effects of hypocaloric feeding.

DESIGN

A meta-analysis of randomized controlled trials (RCTs) and trial sequential analysis (TSA) were carried out.

SETTING

Intensive Care Unit (ICU).

PATIENTS

Or participants Critically ill adults.

INTERVENTIONS

Hypocaloric enteral feeding versus standard enteral feeding.

MAIN VARIABLES OF INTEREST

The primary outcomes were all-cause short-term mortality and the incidence of nosocomial infection.

RESULTS

Eleven RCTs met the inclusion criteria; of these trials, two were judged as having low risk of bias. Compared with standard enteral feeding, hypocaloric enteral feeding had no benefits in terms of reducing short-term mortality, the incidence of nosocomial infection, or long-term mortality, though it had a positive impact upon the incidence of gastrointestinal intolerance. The TSA further confirmed these results. In turn, hypocaloric enteral feeding had no effects upon the incidence of bloodstream infection, pneumonia, hypoglycemia or the duration of mechanical ventilation, ICU stay, or in-hospital stay. The above results remained unchanged in the sub-analysis of trials with a low risk of bias, trials administering a similar dose of protein, or trials administering different doses of protein.

CONCLUSIONS

Compared with standard enteral feeding, hypocaloric enteral feeding was not associated with better clinical outcomes in critically ill adults, except for a lower risk of gastrointestinal intolerance. The difference in protein intake between groups might have no influence on the outcome effects of hypocaloric enteral feeding. High quality randomized controlled trials are needed to confirm this, however.

Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

Background

Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults.

Methods

Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed.

Results

Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09).

Conclusions

SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.