1
|
Wittholz K, Hinckfus C, Karahalios A, Panganiban H, Phillips N, Rotherham H, Rechnitzer T, Ali Abdelhamid Y, Deane AM, Fetterplace K. Association between protocol change to a higher-protein formula with lower energy targets and nutrient delivery in critically ill patients with COVID-19: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:429-439. [PMID: 38477349 DOI: 10.1002/jpen.2620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Guidelines recommend prioritizing protein provision while avoiding excessive energy delivery to critically ill patients with coronavirus disease 2019 (COVID-19), but there are no prospective studies evaluating such a targeted approach in this group. We aimed to evaluate the effect of a "higher-protein formula protocol" on protein, energy, and volume delivery when compared with standard nutrition protocol. METHODS This was a retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation for >72 h and enteral nutrition. Before October 2021, the standard nutrition protocol for patients was 0.7 ml/kg/h ideal body weight (IBW) of a 63 g/L protein and 1250 kcal/L formula. From October 2021, we implemented a higher-protein formula protocol for patients with COVID-19. The initial prescription was 0.5 ml/kg/h IBW of a 100 g/L protein and 1260 kcal/L formula with greater emphasis on energy targets being directed by indirect calorimetry when possible. Measured outcomes included protein, energy, and volume delivered. RESULTS There were 114 participants (standard protocol, 48; higher-protein protocol, 66) with 1324 days of nutrition support. The median (95% CI) differences in protein, energy, and volume delivery between targeted and standard protocol periods were 0.08 g/kg/day (-0.02 to 0.18 g/kg/day), -1.71 kcal/kg/day (-3.64 to 0.21 kcal/kg/day) and -1.5 ml/kg/day (-2.9 to -0.1 ml/kg/day). Thirty-three patients (standard protocol, 7; higher-protein protocol, 26) had 44 indirect calorimetry assessments. There was no difference in measured energy expenditure over time (increased by 0.49 kcal/kg/day [-0.89 to 1.88 kcal/kg/day]). CONCLUSION Implementation of a higher-protein formula protocol to patients with COVID-19 modestly reduced volume administration without impacting protein and energy delivery.
Collapse
Affiliation(s)
- Kym Wittholz
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Chloe Hinckfus
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Amalia Karahalios
- Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Haustine Panganiban
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Nadine Phillips
- Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Hannah Rotherham
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Thomas Rechnitzer
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| |
Collapse
|
2
|
van Ruijven IM, Abma J, Brunsveld-Reinders AH, Stapel SN, van Etten-Jamaludin F, Boirie Y, Barazzoni R, Weijs PJM. High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta-analyses. Clin Nutr 2023; 42:2395-2403. [PMID: 37862825 DOI: 10.1016/j.clnu.2023.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature. METHODS We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies. RESULTS A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass. CONCLUSION High protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.
Collapse
Affiliation(s)
- Isabel M van Ruijven
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands.
| | - José Abma
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anja H Brunsveld-Reinders
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Department of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands
| | - Sandra N Stapel
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Faridi van Etten-Jamaludin
- Amsterdam UMC Location University of Amsterdam, Medical Library AMC, Meibergdreef 9, Amsterdam, the Netherlands
| | - Yves Boirie
- University of Clermont Auvergne, INRAE, CRNH, Clinical Nutrition Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Peter J M Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
3
|
Dickerson RN, Corley CE, Holmes WL, Byerly S, Filiberto DM, Fischer PE. Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade. Nutr Clin Pract 2023; 38:350-359. [PMID: 36156827 DOI: 10.1002/ncp.10911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/23/2022] [Accepted: 08/28/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy. METHODS Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant. RESULTS Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN. CONCLUSION Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.
Collapse
Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Whitney L Holmes
- Department of Pharmacy, Regional One Health, Memphis, Tennessee, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dina M Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
4
|
Dickerson RN, Turner SC, Holmes WL, Van Matre ET, Swanson JM, Byerly S, Filiberto DM, Fischer PE. Reduction in Hypercalcemia Following Readjustment of Target Serum 25-Hydroxy Vitamin D Concentration during Cholecalciferol Therapy in Vitamin D-Deficient Critically Ill Patients. Nutrients 2022; 14:nu14081650. [PMID: 35458212 PMCID: PMC9032836 DOI: 10.3390/nu14081650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
The intent of this study was an evaluation of our effort to reduce the incidence of hypercalcemia in critically ill vitamin D-deficient patients with multiple traumatic injuries given cholecalciferol. Vitamin D deficiency was defined as a serum 25-hydroxy vitamin D concentration (25-OH vit D) of <20 ng/mL. Adult patients (>17 years of age) were given 10,000 IU of cholecalciferol daily with an intended target 25-OH vit D of >19.9 ng/mL. These patients were compared to a historical control group that underwent therapy with a higher target of >29.9 ng/mL. Patients received cholecalciferol via the feeding tube along with enteral nutrition (EN) until the target 25-OH vit D was achieved, EN discontinued, the nutrition support service signed off the patient, or the patient was discharged from the TICU. Patients were included if two consecutive weekly 25-OH vit D were measured. One hundred and three critically ill trauma patients were retrospectively studied. Fifty were given cholecalciferol therapy with the new lower target 25-OH vit D, and 53 were from a historical cohort aiming for the higher target. Hypercalcemia (serum ionized calcium concentration > 1.32 mmol/L) was reduced from 40% (21 out of 53 patients) to 4% (2 out of 50 patients; p < 0.001). None of the hypercalcemic patients were symptomatic. Readjustment of target 25-OH vit D concentration resulted in a ten-fold decrease in the rate of hypercalcemia and improved the safety of cholecalciferol therapy for critically ill patients with traumatic injuries.
Collapse
Affiliation(s)
- Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
- Correspondence:
| | | | - Whitney L. Holmes
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA;
| | - Edward T. Van Matre
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Joseph M. Swanson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee College of Pharmacy, Memphis, TN 38163, USA; (E.T.V.M.); (J.M.S.)
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| | - Peter E. Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (S.B.); (D.M.F.); (P.E.F.)
| |
Collapse
|
5
|
Hinkelmann JV, de Oliveira NA, Marcato DF, Costa ARRO, Ferreira AM, Tomaz M, Rodrigues TJ, Mendes AP. Nutritional Support Protocol for patients with COVID-19. Clin Nutr ESPEN 2022; 49:544-550. [PMID: 35623865 PMCID: PMC8915452 DOI: 10.1016/j.clnesp.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 02/26/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
Abstract
Background & aims COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19. Methods A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients. Results The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge. Conclusion Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.
Collapse
Affiliation(s)
| | | | | | | | | | - Marcilene Tomaz
- Santa Casa de Misericórdia de Juiz de Fora, Minas Gerais, Brazil
| | | | | |
Collapse
|
6
|
Buckley CT, Prasanna N, Mays AL, Tinsley JM, Dickerson RN. Protein requirements for critically ill ventilator-dependent patients with COVID-19. Nutr Clin Pract 2021; 36:984-992. [PMID: 34468046 PMCID: PMC8662189 DOI: 10.1002/ncp.10763] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Recent studies indicate critically ill patients with coronavirus disease 2019 (COVID‐19) are hypermetabolic; however, protein requirements in critically ill COVID‐19 patients are unknown. Our intent was to evaluate the nitrogen accretion response to varying protein intakes for critically ill ventilator‐dependent patients with COVID‐19. Methods Adult patients (age ≥ 18 years) with COVID‐19, admitted to the intensive care unit (ICU) and who required mechanical ventilation were retrospectively evaluated. Patients received continuous enteral nutrition (EN), including supplemental protein boluses, and had a 24‐h urine collection for determination of nitrogen balance (NBAL). Data are expressed as mean ± SD with a P‐value < .05 as significant. Results Twenty‐two patients provided 29 NBAL determinations. Protein intake from EN and protein supplements was 0.9 ± 0.7 g/kg/day at the time of the NBAL with an NBAL of –12.1 ± 10.9 g/day at 7 ± 4 days in the ICU. Combined caloric intake from EN and propofol at the time of the NBAL was 12 ± 8 kcal/kg/day. Nitrogen equilibrium (NBAL of –4 g/day or better) occurred in five patients. Patients achieving nitrogen equilibrium received more protein than those with a negative NBAL (1.2 ± 0.4 g/kg/day vs 0.8 ± 0.8 g/kg/day, P = .046). The linear regression for NBAL in response to graded increases in protein intake was as follows: NBAL = 8.5 × protein intake (g/kg/day) – 18.8 (r = 0.450, P < .001). Conclusion Critically ill ventilator‐dependent patients with COVID‐19 exhibit significant variability in nitrogen accretion response to increases in protein intake and often have a markedly negative NBAL.
Collapse
Affiliation(s)
- Christopher T Buckley
- Department of Pharmacy Practice, Union University, College of Pharmacy, Jackson, Tennessee, USA
| | - Nivedita Prasanna
- Department of Critical Care Medicine, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Abby L Mays
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Jeanette M Tinsley
- Department of Nutrition, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
| | - Roland N Dickerson
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
7
|
Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support. PHARMACY 2021; 9:pharmacy9030121. [PMID: 34287346 PMCID: PMC8293440 DOI: 10.3390/pharmacy9030121] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/16/2021] [Accepted: 06/25/2021] [Indexed: 11/17/2022] Open
Abstract
Propofol, a commonly used sedative in the intensive care unit, is formulated in a 10% lipid emulsion that contributes 1.1 kcals per mL. As a result, propofol can significantly contribute to caloric intake and can potentially result in complications of overfeeding for patients who receive concurrent enteral or parenteral nutrition therapy. In order to avoid potential overfeeding, some clinicians have empirically decreased the infusion rate of the nutrition therapy, which also may have detrimental effects since protein intake may be inadequate. The purpose of this review is to examine the current literature regarding these issues and provide some practical suggestions on how to restrict caloric intake to avoid overfeeding and simultaneously enhance protein intake for patients who receive either parenteral or enteral nutrition for those patients receiving concurrent propofol therapy.
Collapse
|
8
|
Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy. Nutrients 2021; 13:nu13051681. [PMID: 34063391 PMCID: PMC8156106 DOI: 10.3390/nu13051681] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/23/2022] Open
Abstract
The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration > 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance > 149 mL/min/1.73 m2. Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%; p = 0.004), had traumatic brain injury (33% vs. 9%; p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12; p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years; p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL; p = 0.001) and were more catabolic (nitrogen balance of −10.8 ± 13.0 vs. −6.2 ± 9.2 g/d; p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.
Collapse
|