Nutrition During Critical Care: An Audit on Actual Energy and Protein Intakes

Measured Energy Expenditure Using Indirect Calorimetry in Post-Intensive Care Unit Hospitalized Survivors: A Comparison with Predictive Equations

Actual energy needs after a stay in intensive care units (ICUs) are unknown. The aims of this observational study were to measure the energy expenditure (mEE) of ICU survivors during their post-ICU hospitalization period, and to compare this to the estimations of predictive equations (eEE). Survivors of an ICU stay ≥ 7 days were enrolled in the general ward during the first 7 days after ICU discharge. EE was measured using the Q-NRG calorimeter in canopy mode. This measure was compared to the estimated EE using the Harris−Benedict (HB) equation multiplied by a 1.3 stress factor, the Penn−State (PS) equation or the 30 kcal weight-based (WB) equation. A total of 55 adults were included (67.3% male, age 60 (52−67) y, body mass index 26.1 (22.2−29.7) kg/m2). Indirect calorimetry was performed 4 (3−6) d after an ICU stay of 12 (7−16) d. The mEE was 1682 (1328−1975) kcal/d, corresponding to 22.9 (19.1−24.2) kcal/kg/day. The eEE values derived using HB and WB equations were significantly higher than mEE: 3048 (1805−3332) and 2220 (1890−2640) kcal/d, respectively (both p < 0.001). There was no significant difference between mEE and eEE using the PS equation: 1589 (1443−1809) kcal/d (p = 0.145). The PS equation tended to underestimate mEE with a bias of −61.88 kcal and a wide 95% limit of agreement (−717.8 to 594 kcal). Using the PS equation, agreement within 15% of the mEE was found in 32/55 (58.2%) of the patients. In the present cohort of patients who survived a prolonged ICU stay, mEE was around 22−23 kcal/kg/day. In this post-ICU hospitalization context, none of the tested equations were accurate in predicting the EE measured by indirect calorimetry.

An analysis of non-nutritive calories from propofol, dextrose, and citrate among critically ill patients receiving continuous renal replacement therapy

BACKGROUND

Propofol, dextrose, and citrate infusions are necessary treatment modalities in the intensive care units (ICUs). They are, however, a potential source of non-nutritive calories (NNCs) which may cause over-feeding and adverse complications. The literature surrounding the role of NNCs is limited. We aimed to examine the energy contribution of NNCs. Our secondary aim is to assess the nutritional impact of NNCs, especially among patients receiving continuous renal replacement therapy (CRRT).

MATERIALS /METHODS

We enrolled 177 mechanically ventilated patients admitted to medical-surgical ICUs from August to December 2019. Patients were monitored over the first 7 days of admission. Infusion rates of EN/PN and NNCs, as well as clinical characteristics, were examined. Patients receiving CRRT were compared to those without.

RESULTS

In total, 24% received additional energy from citrate. Patients received a maximum of 331kcal from citrate, 492kcal from propofol, and 992kcal from dextrose per ICU day. CRRT-group achieved higher total energy on the first two days (Day 1 - 55.1% vs. 46.4%; p=0.008, Day 2 - 73.2% vs. 55.4%, p=0.025). They also received higher mean NNCs on all days, except for Day 1 (p=0.068).

CONCLUSION

NNCs, especially citrate, are significant sources of energy. Patients receiving CRRT may have greater nutritional risk. There should be close monitoring and adaption of energy prescription accordingly to prevent over-feeding. This article is protected by copyright. All rights reserved.

Medical nutrition therapy and clinical outcomes in critically ill adults: a European multinational, prospective observational cohort study (EuroPN)

BACKGROUND

Medical nutrition therapy may be associated with clinical outcomes in critically ill patients with prolonged intensive care unit (ICU) stay. We wanted to assess nutrition practices in European intensive care units (ICU) and their importance for clinical outcomes.

METHODS

Prospective multinational cohort study in patients staying in ICU ≥ 5 days with outcome recorded until day 90. Macronutrient intake from enteral and parenteral nutrition and non-nutritional sources during the first 15 days after ICU admission was compared with targets recommended by ESPEN guidelines. We modeled associations between three categories of daily calorie and protein intake (low: < 10 kcal/kg, < 0.8 g/kg; moderate: 10-20 kcal/kg, 0.8-1.2 g/kg, high: > 20 kcal/kg; > 1.2 g/kg) and the time-varying hazard rates of 90-day mortality or successful weaning from invasive mechanical ventilation (IMV).

RESULTS

A total of 1172 patients with median [Q1;Q3] APACHE II score of 18.5 [13.0;26.0] were included, and 24% died within 90 days. Median length of ICU stay was 10.0 [7.0;16.0] days, and 74% of patients could be weaned from invasive mechanical ventilation. Patients reached on average 83% [59;107] and 65% [41;91] of ESPEN calorie and protein recommended targets, respectively. Whereas specific reasons for ICU admission (especially respiratory diseases requiring IMV) were associated with higher intakes (estimate 2.43 [95% CI: 1.60;3.25] for calorie intake, 0.14 [0.09;0.20] for protein intake), a lack of nutrition on the preceding day was associated with lower calorie and protein intakes (- 2.74 [- 3.28; - 2.21] and - 0.12 [- 0.15; - 0.09], respectively). Compared to a lower intake, a daily moderate intake was associated with higher probability of successful weaning (for calories: maximum HR 4.59 [95% CI: 1.5;14.09] on day 12; for protein: maximum HR 2.60 [1.09;6.23] on day 12), and with a lower hazard of death (for calories only: minimum HR 0.15, [0.05;0.39] on day 19). There was no evidence that a high calorie or protein intake was associated with further outcome improvements.

CONCLUSIONS

Calorie intake was mainly provided according to the targets recommended by the active ESPEN guideline, but protein intake was lower. In patients staying in ICU ≥ 5 days, early moderate daily calorie and protein intakes were associated with improved clinical outcomes. Trial registration NCT04143503 , registered on October 25, 2019.

Protocol summary and statistical analysis plan for ntensive utrition herapy compard to usual care i criically ill adults (INTENT): a phase II randomised controlled trial

INTRODUCTION

It is plausible that a longer duration of nutrition intervention may have a greater impact on clinical and patient-centred outcomes. The Intensive Nutrition care Therapy comparEd to usual care iN criTically ill adults (INTENT) trial will determine if a whole hospital nutrition intervention is feasible and will deliver more total energy compared with usual care in critically ill patients with at least one organ system failure.

METHODS AND ANALYSIS

This study is a prospective, multicentre, unblinded, parallel-group, phase II randomised controlled trial (RCT) conducted in 23 hospitals in Australia and New Zealand. Mechanically ventilated critically ill adult patients with at least one organ failure who have been in intensive care unit (ICU) for 72-120 hours and meet all of the inclusion and none of the exclusion criteria will be randomised to receive either intensive or usual nutrition care. INTENT started recruitment in October 2018 and a sample size of 240 participants is anticipated to be recruited in 2022. The study period is from randomisation to hospital discharge or study day 28, whichever occurs first, and the primary outcome is daily energy delivery from nutrition therapy. Secondary outcomes include daily energy and protein delivery during ICU and in the post-ICU period, duration of ventilation, ventilator-free days, total bloodstream infection rate and length of hospital stay. All other outcomes are considered tertiary and results will be analysed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Ethics approval has been received in Australia (Alfred Hospital Ethics Committee (HREC/18/Alfred/101) and Human Research Ethics Committee of the Northern Territory Department of Health (2019-3372)) and New Zealand (Northern A Health and Disability Ethics Committee (18/NTA/222). Results will be disseminated in an international peer-reviewed journal(s), at scientific meetings and via social media.

TRIAL REGISTRATION NUMBER

NCT03292237.

How much underfeeding can the critically ill adult patient tolerate?

Critical illness leads to significant metabolic alterations that should be considered when providing nutritional support. Findings from key randomized controlled trials (RCTs) indicate that underfeeding (<70% of energy expenditure [EE]) during the acute phase of critical illness (first 7 days of intensive care unit [ICU] admission) may not be harmful and could instead promote autophagy and prevent overfeeding in light of endogenous energy production. However, the optimal energy target during this period is unclear and full starvation is unlikely to be beneficial. There are limited data regarding the effects of prolonged underfeeding on clinical outcomes in critically ill patients, but recent studies show that oral food intake is suboptimal both in the ICU and following discharge to the acute care setting. It is hypothesized that provision of full nutrition (70-100% of EE) may be important in the recovery phase of critical illness (>7 days of ICU admission) for promoting recovery and rehabilitation; however, studies on nutritional intervention delivered from ICU admission through hospital discharge are needed. The aim of this review is to provide a narrative synthesis of the existing literature on metabolic alterations experienced during critical illness and the impact of underfeeding on clinical outcomes in the critically ill adult patient.

Oral Nutrition during and after Critical Illness: SPICES for Quality of Care!

Malnutrition is associated to poor outcomes in critically ill patients. Oral nutrition is the route of feeding in less than half of the patients during the intensive care unit (ICU) stay and in the majority of ICU survivors. There are growing data indicating that insufficient and/or inadequate intakes in macronutrients and micronutrients are prevalent within these populations. The present narrative review focuses on barriers to food intakes and considers the different points that should be addressed in order to optimize oral intakes, both during and after ICU stay. They are gathered in the SPICES concept, which should help ICU teams improve the quality of nutrition care following 5 themes: swallowing disorders screening and management, patient global status overview, involvement of dieticians and nutritionists, clinical evaluation of nutritional intakes and outcomes, and finally, supplementation in macro-or micronutrients.