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Moon K, McKinnon E, Croft K, Mori TA, Simmer K, Patole S, Rao S. Early versus late parenteral nutrition in term and late preterm infants: a randomised controlled trial. BMJ Paediatr Open 2024; 8:e002579. [PMID: 38735834 PMCID: PMC11097870 DOI: 10.1136/bmjpo-2024-002579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND There is limited evidence regarding the optimal time to commence parenteral nutrition (PN) in term and late preterm infants. DESIGN Single-centre, non-blinded, exploratory randomised controlled trial. SETTING A level-3 neonatal unit in a stand-alone paediatric hospital. PATIENTS Infants born ≥34 weeks of gestation and ≤28 days, who needed PN. Eligible infants were randomised on day 1 or day 2 of admission. INTERVENTIONS Early (day 1 or day 2 of admission, N=30) or late (day 6 of admission, N=30) PN. MAIN OUTCOME MEASURES Plasma phenylalanine and F2-isoprostane levels on day 4 and day 8 of admission. Secondary outcomes were amino-acid and fatty-acid profiles on day 4 and day 8, and clinical outcomes. RESULTS The postnatal age at randomisation was similar between the groups (2.3 (SD 0.8) vs 2.3 (0.7) days, p=0.90). On day 4, phenylalanine levels in early-PN infants were higher than in late-PN (mean (SD) 62.9 (26.7) vs 45.5 (15.3) µmol/L; baseline-adjusted percentage difference 25.8% (95% CI 11.6% to 39.9%), p<0.001). There was no significant difference in phenylalanine levels between the two groups on day 8. There was no significant difference between the groups for F2-isoprostane levels on day 4 (early-PN mean (SD) 389 (176) vs late-PN 419 (291) pg/mL; baseline-adjusted percentage difference: -4.4% (95% CI -21.5% to 12.8%) p=0.62) and day 8 (mean (SD) 305 (125) vs 354 (113) pg/mL; adjusted mean percentage difference -16.1 (95% CI -34.1 to 1.9) p=0.09).Postnatal growth restriction for weight was less severe in the early-PN group (change in weight z-score from baseline to discharge: -0.6 (0.6) vs -1.0 (0.6); p=0.02). The incidence of hyperglycaemia was greater in the early-PN group (20/30 (66.7%) vs 11/30 (36.7%), p=0.02). CONCLUSIONS The timing of the commencement of PN did not seem to affect the degree of oxidative stress in critically ill term and late preterm infants. The effect of transiently high plasma phenylalanine with early PN on clinical outcomes requires further investigation. TRIAL REGISTRATION NUMBER ACTRN12620000324910.
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Affiliation(s)
- Kwi Moon
- Pharmacy Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth McKinnon
- Telethon Institute for Child Health Research, Nedlands, Western Australia, Australia
| | - Kevin Croft
- The University of Western Australia School of Biomedical Sciences, Nedlands, Western Australia, Australia
| | - Trevor A Mori
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Karen Simmer
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Sanjay Patole
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Neonatology, King Edward Memorial Hospital for Women Perth, Subiaco, Western Australia, Australia
| | - Shripada Rao
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Unoki T, Hayashida K, Kawai Y, Taito S, Ando M, Iida Y, Kasai F, Kawasaki T, Kozu R, Kondo Y, Saitoh M, Sakuramoto H, Sasaki N, Saura R, Nakamura K, Ouchi A, Okamoto S, Okamura M, Kuribara T, Kuriyama A, Matsuishi Y, Yamamoto N, Yoshihiro S, Yasaka T, Abe R, Iitsuka T, Inoue H, Uchiyama Y, Endo S, Okura K, Ota K, Otsuka T, Okada D, Obata K, Katayama Y, Kaneda N, Kitayama M, Kina S, Kusaba R, Kuwabara M, Sasanuma N, Takahashi M, Takayama C, Tashiro N, Tatsuno J, Tamura T, Tamoto M, Tsuchiya A, Tsutsumi Y, Nagato T, Narita C, Nawa T, Nonoyama T, Hanada M, Hirakawa K, Makino A, Masaki H, Matsuki R, Matsushima S, Matsuda W, Miyagishima S, Moromizato M, Yanagi N, Yamauchi K, Yamashita Y, Yamamoto N, Liu K, Wakabayashi Y, Watanabe S, Yonekura H, Nakanishi N, Takahashi T, Nishida O. Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023). J Intensive Care 2023; 11:47. [PMID: 37932849 PMCID: PMC10629099 DOI: 10.1186/s40560-023-00697-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023] Open
Abstract
Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.
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Affiliation(s)
- Takeshi Unoki
- Department Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan.
| | - Kei Hayashida
- Department of Emergency Medicine, South Shore University Hospital, Northwell Health, Bay Shore, NY, USA
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Shunsuke Taito
- Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Morihide Ando
- Department of Pulmonary Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yuki Iida
- Faculty of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Fumihito Kasai
- Department of Rehabilitation Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masakazu Saitoh
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Japan
| | - Nobuyuki Sasaki
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryuichi Saura
- Department of Rehabilitation Medicine, Division of Comprehensive Medicine, Osaka Medical and Pharmaceutical University School of Medicine, Takatsuki, Japan
| | - Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Saiko Okamoto
- Department of Nursing, Hitachi General Hospital, Hitachi, Japan
| | - Masatsugu Okamura
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tomoki Kuribara
- Department Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yujiro Matsuishi
- School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Norimasa Yamamoto
- Department of Nursing, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shodai Yoshihiro
- Department of Pharmaceutical Services, Hiroshima University Hospital, Hiroshima, Japan
| | - Taisuke Yasaka
- Global Nursing Research Center, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Ryo Abe
- Department of Rehabilitation, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takahito Iitsuka
- Department of Rehabilitation, Amagasaki Daimotsu Rehabilitation Hospital, Amagasaki, Japan
| | - Hiroyasu Inoue
- Department of Rehabilitation, Showa University School of Nursing and Rehabilitation Sciences, Yokohama, Japan
| | - Yuki Uchiyama
- Department of Rehabilitation Medicine, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Satoshi Endo
- Rehabilitation Center, Amayama Hospital, Matsuyama, Japan
| | - Kazuki Okura
- Division of Rehabilitation, Akita University Hospital, Akita, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahisa Otsuka
- Department of Rehabilitation Medicine, Okayama University Hospital, Okayama, Japan
| | - Daisuke Okada
- Department of Rehabilitation, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kengo Obata
- Department of Rehabilitation, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Yukiko Katayama
- Department of Nursing, Sakakibara Heart Institute, Fuchu, Japan
| | - Naoki Kaneda
- Rehabilitation Division, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Mio Kitayama
- Nursing Department, Kanazawa Medical University Hospital, Uchinada, Japan
| | - Shunsuke Kina
- Department of Rehabilitation, Nakagami Hospital, Okinawa, Japan
| | - Ryuichi Kusaba
- Department of Rehabilitation Medicine, Kyushu University Hospital, Fukuoka, Japan
| | | | - Naoki Sasanuma
- Department of Rehabilitation, Hyogo Medical University Hospital, Nishinomiya, Japan
| | | | | | - Naonori Tashiro
- Rehabilitation Center, Showa University Hospital, Tokyo, Japan
| | - Junko Tatsuno
- Department of Nursing, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Takahiko Tamura
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Nankoku, Japan
| | - Mitsuhiro Tamoto
- Department of Nursing, Kyoto University Hospital, Kyoto, Kyoto, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yusuke Tsutsumi
- Department of Emergency Medicine, National Hospital Organization Mito Medical Center, Mito, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine and Infectious Diseases, JCHO Tokyo Yamate Medical Center, Tokyo, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomohiro Nawa
- Department of Pediatric Cardiology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Tadayoshi Nonoyama
- Department of Rehabilitation, University of Fukui Hospital, Fukui, Japan
| | - Masatoshi Hanada
- Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kotaro Hirakawa
- Department of Rehabilitation, Sakakibara Heart Institute, Fuchu, Japan
| | - Akiko Makino
- School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Hirotaka Masaki
- Department of Nursing, Nagoya University Hospital, Nagoya, Japan
| | - Ryosuke Matsuki
- Department of Rehabilitation, Kansai Electric Power Hospital, Osaka, Japan
| | | | - Wataru Matsuda
- Department of Emergency Medicine & Critical Care, Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Japan
| | - Saori Miyagishima
- Division of Rehabilitation, Sapporo Medical University Hospital, Hokkaido, Japan
| | - Masaru Moromizato
- Department of Nursing, Chubu Tokushukai Hospital, Kitanakagusuku, Japan
| | - Naoya Yanagi
- Department of Rehabilitation, Kitasato University Medical Center, Kitamoto, Japan
| | - Kota Yamauchi
- Department of Rehabilitation, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Yuhei Yamashita
- Division of Rehabilitation Medicine, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Natsuhiro Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), Tokyo, Japan
| | - Yuki Wakabayashi
- Department of Nursing, Kobe City Center General Hospital, Kobe, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, Gifu, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan
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Impact of Energy and Protein Delivery to Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2022; 14:nu14224849. [PMID: 36432536 PMCID: PMC9698683 DOI: 10.3390/nu14224849] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
Optimal energy and protein delivery goals for critically ill patients remain unknown. The purpose of this systematic review and meta-analysis was to compare the impact of energy and protein delivery during the first 4 to 10 days of an ICU stay on physical impairments. We performed a systematic literature search of MEDLINE, CENTRAL, and ICHUSHI to identify randomized controlled trials (RCTs) that compared energy delivery at a cut-off of 20 kcal/kg/day or 70% of estimated energy expenditure or protein delivery at 1 g/kg/day achieved within 4 to 10 days after admission to the ICU. The primary outcome was activities of daily living (ADL). Secondary outcomes were physical functions, changes in muscle mass, quality of life, mortality, length of hospital stay, and adverse events. Fifteen RCTs on energy delivery and 14 on protein were included in the analysis. No significant differences were observed in any of the outcomes included for energy delivery. However, regarding protein delivery, there was a slight improvement in ADL (odds ratio 21.55, 95% confidence interval (CI) −1.30 to 44.40, p = 0.06) and significantly attenuated muscle loss (mean difference 0.47, 95% CI 0.24 to 0.71, p < 0.0001). Limited numbers of RCTs were available to analyze the effects of physical impairments. In contrast to energy delivery, protein delivery ≥1 g/kg/day achieved within 4 to 10 days after admission to the ICU significantly attenuated muscle loss and slightly improved ADL in critically ill patients. Further RCTs are needed to investigate their effects on physical impairments.
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Moon K, Mckinnon E, Croft K, Hendrie D, Patole S, Simmer K, Rao S. Early versus late parenteral nutrition in term and late preterm infants: study protocol for a randomised controlled trial. BMC Pediatr 2022; 22:514. [PMID: 36042439 PMCID: PMC9429301 DOI: 10.1186/s12887-022-03569-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the wide use of parenteral nutrition (PN) in neonatal intensive care units (NICU), there is limited evidence regarding the optimal time to commence PN in term and late preterm infants. The recommendations from the recently published ESPGHAN/ESPEN/ESPR/CPEN and NICE guidelines are substantially different in this area, and surveys have reported variations in clinical practice. The aim of this randomised controlled trial (RCT) is to evaluate the benefits and risks of early versus late PN in term and late preterm infants. METHODS/DESIGN This study is a single-centre, non-blinded RCT in the NICU of Perth Children's Hospital, Western Australia.A total of 60 infants born ≥34 weeks of gestation who have a high likelihood of intolerance to enteral nutrition (EN) for at least 3-5 days will be randomised to early (day 1 or day 2 of admission) or late commencement (day 6 of admission) of PN after informed parental consent. In both groups, EN will be commenced as early as clinically feasible. Primary outcomes are plasma phenylalanine and plasma F2-isoprostane levels on Day 4 and Day 8 of admission. Secondary outcomes are total and individual plasma amino acid profiles, plasma and red blood cell fatty acid profiles, in-hospital all-cause mortality, hospital-acquired infections, length of hospital/NICU stay, z scores and changes in z scores at discharge for weight, height and head circumference, time to full EN, duration of respiratory (mechanical, non-invasive) support, duration of inotropic support, the incidence of hyper and hypoglycaemia, incidence of metabolic acidosis, liver function, blood urea nitrogen, and C-reactive protein (CRP). DISCUSSION This RCT will examine the effects of early versus late PN in term and late preterm infants by comparing key biochemical and clinical outcomes and has the potential to identify underlying pathways for beneficial or harmful effects related to the timing of commencement of PN in such infants. TRIAL REGISTRATION ANZCTR; ACTRN12620000324910 (3rd March 2020).
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Affiliation(s)
- Kwi Moon
- Pharmacy Department, Perth Children's Hospital, 15 Hospital Ave, Nedlands, WA, 6009, Australia.
- Medical School, The University of Western Australia, Perth, WA, Australia.
| | | | - Kevin Croft
- School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Delia Hendrie
- School of Public Health Sciences, Curtin University, Perth, WA, Australia
| | - Sanjay Patole
- Medical School, The University of Western Australia, Perth, WA, Australia
- Department of Neonatology, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Karen Simmer
- Medical School, The University of Western Australia, Perth, WA, Australia
- Telethon Kids Institute, Nedlands, WA, Australia
| | - Shripada Rao
- Medical School, The University of Western Australia, Perth, WA, Australia
- Department of Neonatology, Perth Children's Hospital, Nedlands, WA, Australia
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McKeever L, Peterson SJ, Lateef O, Braunschweig C. The Influence of Timing in Critical Care Nutrition. Annu Rev Nutr 2021; 41:203-222. [PMID: 34143642 DOI: 10.1146/annurev-nutr-111120-114108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Proper timing of critical care nutrition has long been a matter of controversy. Critical illness waxes and wanes in stages, creating a dynamic flux in energy needs that we have only begun to examine. Furthermore, response to nutrition support likely differs greatly at the level of the individual patient in regard to genetic status, disease stage, comorbidities, and more. We review the observational and randomized literature concerning timing in nutrition support, discuss mechanisms of harm in feeding critically ill patients, and highlight the role of precision nutrition for moving the literature beyond the realm of blunt population averages into one that accounts for the patient-specific complexities of critical illness and host genetics. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Liam McKeever
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania 19063, USA;
| | - Sarah J Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois 60612, USA
| | - Omar Lateef
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois 60612, USA
| | - Carol Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois 60612, USA;
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Jiang H, Zhang JC, Zeng J, Wang L, Wang Y, Lu CD, Deng L, Deng H, Wang K, Sun MW, Zhou P, Yuan T, Chen W. Gut, metabolism and nutritional Support for COVID-19: Experiences from China. BURNS & TRAUMA 2020; 8:tkaa048. [PMID: 33654695 PMCID: PMC7901705 DOI: 10.1093/burnst/tkaa048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/23/2020] [Indexed: 12/22/2022]
Abstract
There is little research that focuses on the relationship between the gut, metabolism, nutritional support and COVID-19. As a group of Chinese physicians, nutritionists and scientists working on the frontline treating COVID-19 patients, we aim to integrate our experiences and the current clinical evidence to address this pressing issue in this article. Based on our clinical observations and available evidence, we recommend the following practice. Firstly, the Nutritional Risk Screening 2002 tool should be used routinely and periodically; for patients with a score ≥3, oral nutritional supplements should be given immediately. Secondly, for patients receiving the antiviral agents lopinavir/ritonavir, gastrointestinal side effects should be monitored for and timely intervention provided. Thirdly, for feeding, the enteral route should be the first choice. In patients undergoing mechanical ventilation, establishing a jejunal route as early as possible can guarantee the feeding target being achieved if gastric dilatation occurs. Fourthly, we suggest a permissive underfeeding strategy for severe/critical patients admitted to the intensive care unit during the first week of admission, with the energy target no more than 20 kcal/kg/day (for those on mechanical ventilation, this target may be lowered to 10-15 kcal/kg/day) and the protein target around 1.0-1.2 g/kg/day. If the inflammatory condition is significantly alleviated, the energy target may be gradually increased to 25-30 kcal/kg/day and the protein target to 1.2-1.5 g/kg/day. Fifthly, supplemental parenteral nutrition should be used with caution. Lastly, omega-3 fatty acids may be used as immunoregulators, intravenous administration of omega-3 fatty emulsion (10 g/day) at an early stage may help to reduce the inflammatory reaction.
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Affiliation(s)
- Hua Jiang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Jian-Cheng Zhang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Jun Zeng
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Lu Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Yu Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Charles Damien Lu
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Lei Deng
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Medical Task Force of Sichuan Provincial People’s Hospital to Union Red Cross Hospital of Wuhan, Wuhan, 430015, China
| | - Hongfei Deng
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Kai Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ming-Wei Sun
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ping Zhou
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ting Yuan
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Wei Chen
- Department of Clinical Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuai fu yuan Wang fu jing Dong cheng District, Beijing, 100730, China
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McKeever L, Peterson SJ, Lateef O, Freels S, Diamond AM, Braunschweig CA. Impact of MnSOD and GPx1 Genotype at Different Levels of Enteral Nutrition Exposure on Oxidative Stress and Mortality: A Post hoc Analysis From the FeDOx Trial. JPEN J Parenter Enteral Nutr 2020; 45:287-294. [PMID: 32885455 DOI: 10.1002/jpen.2012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Converting nutrition support to energy results in mitochondrial free radical production, possibly increasing oxidative stress. Highly prevalent single nucleotide variants (SNV) exist for the genes encoding antioxidant enzymes responsible for the detoxification of reactive oxygen species. Our objective was to explore the interaction between nutrition support and genetic SNV's for two anti-oxidant proteins (rs4880 SNV for manganese superoxide dismutase and rs1050450 SNV for glutathione peroxidase 1) on oxidative stress and secondarily on intensive care unit (ICU) mortality. METHODS We performed a post-hoc analysis on 34 mechanically ventilated sepsis patients from a randomized control feeding trial. Participants were dichotomized into those who carried both the rs4880 and the rs1050450 at-risk alleles (Risk Group) versus all others (Nonrisk Group). We explored the interaction between genotype and percent time spent in the upper median of energy exposure on oxidative stress and ICU mortality. RESULTS Adjusting for confounders, the slope of log F2-isoprostane levels across percentage of days spent in the upper median of daily kilocalories per kilogram (kcal/kg) was 0.01 higher in the Risk Group compared to the Non-Risk Group (p=0.01). Every 1 percent increase in days spent in the upper median of daily kcal/kg was associated with an adjusted 10.3 percent increased odds of ICU mortality amongst participants in the Risk Group (odds ratio [OR]=1.103, p=0.06) but was highly insignificant in the Nonrisk group (OR=0.991, P=0.79). CONCLUSION Nutrition support may lead to increased oxidative stress and worse clinical outcomes in a large percent of ICU patients with an at-risk genotype.
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Affiliation(s)
- Liam McKeever
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah J Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Omar Lateef
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Sally Freels
- Department of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alan M Diamond
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Carol A Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
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