Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle

Challenges Encountered in the Provision of Enteral Nutrition in Pediatric Intensive Care Unit: An Observational Study

Background Enteral nutrition (EN) represents the preferred modality for nutrient administration in critically ill patients. However, it is fraught with challenges such as delayed initiation and recurrent interruptions, which can significantly impact patient clinical outcomes. A substantial proportion of these interruptions can be mitigated. In the present investigation, our objective was to scrutinize the practice of EN in the Pediatric Intensive Care Unit (PICU). We sought to ascertain the frequency and underlying causes of EN interruptions and assess their ramifications for nutrient delivery. Study design We conducted an observational study within the PICU of Mahatma Gandhi Mission's (MGM) Medical College and Hospital, Aurangabad. The study encompassed children admitted to the PICU for a period exceeding 24 hours who were receiving enteral feeds. We documented the time of commencing EN from the point of PICU admission, instances of enteral feeding interruptions, the number and duration of each interruption episode, and the reasons behind these interruptions. Subsequently, we categorized the causes of feeding interruptions into avoidable and non-avoidable determinants. Results Out of the 100 patients enrolled in this study, only 34% presented with normal nutritional status upon admission. Sixty-five percent of patients had their nutritional support initiated within the first 48 hours of admission to the PICU. The median duration from PICU admission to the initiation of EN was 32.5 hours, with a median interruption duration per patient of 40.96 hours. Common causes of interruptions included radiological procedures, respiratory distress, altered sensorium, presence of gastric aspirates, and surgical procedures. Upon analysis, it was determined that a substantial majority, constituting 74%, of these interruptions were avoidable. Conclusions The primary challenges associated with EN in the PICU encompass delayed initiation of enteral feeds and frequent interruptions. Importantly, a significant proportion of these issues are avoidable.

How do guideline recommended energy targets compare with measured energy expenditure in critically ill adults with obesity: A systematic literature review

BACKGROUND

Critically ill patients with obesity have unique and complex nutritional needs, with clinical practice guidelines conflicting regarding recommended energy targets. The aim of this systematic review was to 1) describe measured resting energy expenditure (mREE) reported in the literature and; 2) compare mREE to predicted energy targets using the European (ESPEN) and American (ASPEN) guideline recommendations when indirect calorimetry is not available in critically ill patients with obesity.

METHODS

The protocol was registered apriori and literature was searched until 17th March, 2022. Original studies were included if they reported mREE using indirect calorimetry in critically ill patients with obesity (BMI≥30 kg/m²). Group-level mREE data was reported as per the primary publication using mean ± standard deviation or median [interquartile range]. Where individual patient data was available, Bland-Altman analysis was used to assess mean bias (95% limits of agreement) between guideline recommendations and mREE targets (i.e. ASPEN for BMI 30-50, 11-14 kcal/kg actual weight compared to 70% mREE and ESPEN 20-25 kcal/kg adjusted weight compared to 100% mREE). Accuracy was assessed by the percentage (%) of estimates within ±10% of mREE targets.

RESULTS

After searching 8019 articles, 24 studies were included. mREE ranged from 1607 ± 385 to 2919 [2318-3362]kcal and 12-32kcal/actual body weight. For the ASPEN recommendations of 11-14 kcal/kg, a mean bias of -18% (-50% to +13%) and 4% (-36% to +44%) was observed, respectively (n = 104). For the ESPEN recommendations 20-25 kcal/kg, a bias of -22% (-51% to +7%) and -4% (-43% to +34%), was observed, respectively (n = 114). The guideline recommendations were able to accurately predict mREE targets on 30%-39% occasions (11-14 kcal/kg actual) and 15%-45% occasions (20-25 kcal/kg adjusted), for ASPEN and ESPEN recommendations, respectively.

CONCLUSIONS

Measured energy expenditure in critically ill patients with obesity is variable. Energy targets generated using predictive equations recommended in both the ASPEN and ESPEN clinical guidelines have poor agreement with mREE and are frequently not able to accurately predict within ±10% of mREE, most commonly underestimating energy needs.

Changes in Nutrition-Intake Method and Oral Health through a Multidisciplinary Team Approach in Malnourished Older Patients Admitted to an Acute Care Hospital

Malnourished older inpatients referred to a nutrition support team (NST) usually receive multidisciplinary oral health management during NST intervention. However, the effects of multidisciplinary oral health management on the nutrition-intake method and oral health in these patients remain unclear. This longitudinal study aimed to investigate the effects of NST-mediated multidisciplinary oral health management on the nutrition-intake methods, oral health, and the systemic and oral factors influencing the changes in the nutrition-intake method. A total of 117 inpatients (66 men, 51 women, mean age, 71.9 ± 12.5 years) who underwent NST-mediated multidisciplinary oral health management between April 2016 and July 2019 were enrolled. Demographic data and Functional Oral Intake Scale (FOIS), Dysphagia Severity Scale (DSS), and Oral Health Assessment Tool (OHAT) scores at the time of referral to the NST and completion of the NST intervention were evaluated. After multidisciplinary NST intervention, FOIS, DSS, and OHAT scores showed significant improvements (p < 0.001). Even after adjusting the results for systemic parameters, FOIS score improvement correlated positively with the length of NST intervention (p = 0.030) and DSS score improvement (p < 0.001) as well as OHAT score improvement (p = 0.047). NST interventions with multidisciplinary oral health management could improve the nutrition-intake method.

Probiotic Supplementation Prevents the Development of Ventilator-Associated Pneumonia for Mechanically Ventilated ICU Patients: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Background

Ventilator-associated pneumonia (VAP) is one of the common critical complications of nosocomial infection (NI) in invasive mechanically ventilated intensive care unit (ICU) patients. The efficacy of total parenteral nutrition (TPN), enteral nutrition and/or adjuvant peripheral parenteral nutrition (EPN) supplemented with or without probiotic, prebiotic, and synbiotic therapies in preventing VAP among these patients has been questioned. We aimed to systematically and comprehensively summarize all available studies to generate the best evidence of VAP prevention for invasive mechanically ventilated ICU patients.

Methods

Randomized controlled trials (RCTs) for the administration of TPN, EPN, probiotics-supplemented EPN, prebiotics-supplemented EPN, and synbiotics-supplemented EPN for VAP prevention in invasive mechanically ventilated ICU patients were systematically retrieved from four electronic databases. The incidence of VAP was the primary outcome and was determined by the random-effects model of a Bayesian framework. The secondary outcomes were NI, ICU and hospital mortality, ICU and hospital length of stay, and mechanical ventilation duration. The registration number of Prospero is CRD42020195773.

Results

A total of 8339 patients from 31 RCTs were finally included in network meta-analysis. The primary outcome showed that probiotic-supplemented EPN had a higher correlation with the alleviation of VAP than EPN in critically invasive mechanically ventilated patients (odds ratio [OR] 0.75; 95% credible intervals [CrI] 0.58–0.95). Subgroup analyses showed that probiotic-supplemented EPN prevented VAP in trauma patients (OR 0.30; 95% CrI 0.13–0.83), mixed probiotic strain therapy was more effective in preventing VAP than EPN therapy (OR 0.55; 95% CrI 0.31–0.97), and low-dose probiotic therapy (less than 10¹⁰ CFU per day) was more associated with lowered incidence of VAP than EPN therapy (OR 0.16; 95% CrI 0.04–0.64). Secondary outcomes indicated that synbiotic-supplemented EPN therapy was more significantly related to decreased incidence of NI than EPN therapy (OR 0.34; 95% CrI 0.11–0.85). Prebiotic-supplemented EPN administration was the most effective in preventing diarrhea (OR 0.05; 95% CrI 0.00–0.71).

Conclusion

Probiotic supplementation shows promise in reducing the incidence of VAP in critically invasive mechanically ventilated patients. Currently, low quality of evidence reduces strong clinical recommendations. Further high-quality RCTs are needed to conclusively prove these findings.

Systamatic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020195773], identifier [CRD42020195773].

Nutritional status disorders and methods of their correction in patients with advanced pancreatic cancer

Despite of achieved progress in advanced pancreatic cancer treatment, the disease outcomes remain far from satisfying. The peculiarity of malnutrition treatment in these patients is the result of its causes complexity and progressively growing manifestations extent. The review represents mechanisms of malnutrition and approaches to their treatment.

Doubly labelled water for determining total energy expenditure in adult critically ill and acute care hospitalized inpatients: A scoping review

BACKGROUND & AIMS

Doubly labelled water (DLW) is considered the reference standard method of measuring total energy expenditure (TEE), but there is limited information on its use in the Intensive Care Unit (ICU) and acute care setting. This scoping review aims to systematically summarize the available literature on TEE measured using DLW in these contexts.

METHODS

Four online databases (MEDLINE, Embase, Emcare and CINAHL) were searched up to Dec 12, 2020. Studies in English were included if they measured TEE using DLW in adults in the ICU and/or acute care setting. Key considerations, concerns and practical recommendations were identified and qualitatively synthesized.

RESULTS

The search retrieved 7582 studies and nine studies were included; one in the ICU and eight in the acute care setting. TEE was measured over 7-15-days, in predominantly clinically stable patients. DLW measurements were not commenced until four days post admission or surgery in one study and following a 10-14-day stabilization period on parenteral nutrition (PN) in three studies. Variable dosages of isotopes were administered, and several equations used to calculate TEE. Four main considerations were identified with the use of DLW in these settings: variation in background isotopic abundance; excess isotopes leaving body water as carbon dioxide or water; fluctuations in rates of isotope elimination and costs.

CONCLUSION

A stabilization period on intravenous fluid and PN regimens is recommended prior to DLW measurement. The DLW technique can be utilized in medically stable ICU and acute care patients, with careful considerations given to protocol design.

Nutrition support for critically ill patients

Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.

Effect of Early Versus Delayed Parenteral Nutrition on the Health Outcomes of Critically Ill Adults: A Systematic Review

Objectives

This systematic review aims to evaluate and summarise the findings of all relevant studies which identified the effect of early vs delayed parenteral nutrition (PN), early PN vs early supplemental PN and early PN vs standard care for critically ill adults.

Methods

The literature search was undertaken using PubMed, Embase, Medline, Clinical Key, and Ovid discovery databases. The reference lists of studies published from 2000 till June 2020 were hand searched.

Result

On screening 2088 articles, a total of five RCTs with 6,277 patients were included in this review. Only one clinical trial compared early PN and late PN; the results reported significantly shorter periods in intensive care unit (ICU) stay (p=0.02) and less ICU related infections (p=0.008) in the late PN group compared to the Early PN group. Two trials compared total parenteral nutrition (TPN) and enteral nutrition (EN) +TPN groups. Both found a significantly longer hospital stay duration (p<0.05 and p<0.01) with a higher mortality rate in the TPN group compared to the EN+TPN group. A statistically significant improvement was observed in patients' quality of life receiving early PN compared to standard care (p=0.01). In contrast, no significant difference was found in the supplemental PN vs the standard care group.

Conclusion

The supplemental PN patients had shorter ICU stay and lower mortality rates than TPN. However, these findings should be interpreted carefully as included studies have different initiation timing of nutritional support, and the patients' diagnosis varied.

Micronutrient intake from enteral nutrition in critically ill adults: A systematic review of randomised controlled trials

OBJECTIVES

The primary objective was to compare the intake of important micronutrients provided from enteral nutrition to critically ill patients with the Australia and New Zealand recommended dietary intakes. A secondary objective was to compare the upper levels of intake and investigate prespecified subgroups.

REVIEW METHOD USED

A systematic literature review was performed.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and CENTRAL were used.

REVIEW METHODS

Databases were searched for randomised controlled trials that investigated an enteral nutrition intervention as the sole source of nutrition, were published in English between January 2000 and January 8th, 2021, and provided data to calculate micronutrient intake. The primary outcome was the % recommended dietary intake. The quality of individual trials was assessed using the Cochrane Risk of Bias Tool. Outcomes are presented as either mean ± standard deviation or median [interquartile range], with a p < 0.05 considered statistically significant.

RESULTS

Thirteen trials were included (n = 1538 patients). Trials investigating hypocaloric nutrition were excluded from the primary outcome assessment (conducted in nine trials (n = 1220)). All nine trials delivered ≥104% of the recommended dietary intakes and <100% of the upper level of intakes of all micronutrients. In subgroup analyses, trials with ≥80% target energy delivered a higher % of the recommended dietary intake of vitamin B12, thiamine, zinc, and vitamin C. Acute Physiology and Chronic Health Evaluation scores ≥20 delivered a higher % of the recommended dietary intake of vitamin B12 and vitamin A. Antioxidant formulas compared with standard formulas delivered a higher % recommended dietary intake of vitamin C and thiamine. In the four trials that investigated hypocaloric feeding compared with control, there was no difference in micronutrient intake. The quality was low.

CONCLUSIONS

Enteral nutrition delivery frequently met the recommended dietary intakes for all micronutrients investigated and did not exceed the upper levels of intake set for health.

PROSPERO REGISTRATION

CRD42020178333.

Stress Hyperglycemia and Osteocalcin in COVID-19 Critically Ill Patients on Artificial Nutrition

We aimed to study the possible association of stress hyperglycemia in COVID-19 critically ill patients with prognosis, artificial nutrition, circulating osteocalcin, and other serum markers of inflammation and compare them with non-COVID-19 patients. Fifty-two critical patients at the intensive care unit (ICU), 26 with COVID-19 and 26 non-COVID-19, were included. Glycemic control, delivery of artificial nutrition, serum osteocalcin, total and ICU stays, and mortality were recorded. Patients with COVID-19 had higher ICU stays, were on artificial nutrition for longer (p = 0.004), and needed more frequently insulin infusion therapy (p = 0.022) to control stress hyperglycemia. The need for insulin infusion therapy was associated with higher energy (p = 0.001) and glucose delivered through artificial nutrition (p = 0.040). Those patients with stress hyperglycemia showed higher ICU stays (23 ± 17 vs. 11 ± 13 days, p = 0.007). Serum osteocalcin was a good marker for hyperglycemia, as it inversely correlated with glycemia at admission in the ICU (r = -0.476, p = 0.001) and at days 2 (r = -0.409, p = 0.007) and 3 (r = -0.351, p = 0.049). In conclusion, hyperglycemia in critically ill COVID-19 patients was associated with longer ICU stays. Low circulating osteocalcin was a good marker for stress hyperglycemia.

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.

Does ultrasonographic assessment of gastric antrum correlate with gastric residual volume in critically ill patients? A prospective observational study

This study aimed to evaluate the relationship between ultrasonographic gastric antral measurements and aspirated gastric residual volume (GRV) in mechanically ventilated critically ill patients receiving enteral nutrition (EN). This prospective observational study included 56 enterally-fed critically ill patients in one-year period. All imaging procedures were done at 30-degree head-of-bed elevation and supine position on epigastric region of abdomen with 2.5-6 MHz convex-array probe just before routine GRV aspiration. The antral cross-sectional area (CSA) was calculated by measuring the anteroposterior (dAP) and craniocaudal diameters (dCC) of the gastric antrum. Total 283 ultrasonographic gastric antrum imaging procedures were done. In only eight (2.82%) attempts, the antrum could not be visualized due to inhibition from intra-gastric air or gas in the surrounding intestinal lumen. The calculated mean antral CSA was 568.15 ± 348.37 mm² (103.43-2,846.30). The antral CSA correlated significantly with aspirated GRV, and the antral CSA increased linearly with increasing aspirated GRV (R² = 0.73, p < 0.0001). In Receiver operating characteristic (ROC) analysis of antral CSA ≥ 920 mm² (mean + 1*SD) for estimating aspirated GRV, the area under the curve (AUC) was 0.848 (95% CI, 0.76 ~ 0.93) (p < 0.0001), and ROC analysis of antral CSA to discriminate aspirated GRV ≥ 250 mL showed a significant relation (AUC = 0.969, 95% CI 0.94 ~ 0.99, p < 0.0001). Ultrasonographic measurement of gastric antral CSA is an easy and reliable bedside procedure to estimate GRV in critically ill patients receiving EN in 30-degree head-of-bed elevation and supine position. Trial registration number: NCT04413474, date of registration: June 17, 2020, retrospectively registered.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective

To avoid perioperative complications caused malnutrition, nutrition therapy is necessary in gastric outlet obstruction (GOO) patients. Compared to parenteral nutrition (PN), enteral nutrition (EN) is associated with many advantages. This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.

Methods

According to the methods of preoperative nutrition therapy, 143 patients were divided into EN group (n=42) and PN group (n=101) between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital. Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage. The generalized additive model and two-piecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.

Results

EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO, which is a protective factor, especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy (>3 d) did not accelerate the postoperative recovery of gastrointestinal functions.

Conclusions

Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery. For patients with absolute obstruction, no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Prevention and Therapy of AKI in Asia: A Big Challenge

Asia is the largest and most populous continent and has huge differences in socioeconomic status, development, and health care between the different countries and regions within each country. This manifests in the varied causes of acute kidney injury (AKI), particularly higher rates of community-acquired AKI and in the differential access to health care for the population. Because of resource limitations, prevention and treatment of AKI is a difficult challenge. This review highlights the differences in AKI in Asia compared with the developed world and discusses prevention and treatment of AKI within the context of resource limitations.

Reporting of Randomized Controlled Trials Investigating an Enteral or Parenteral Nutrition Intervention in Critical Illness According to the CONSORT Statement: A Systematic Review and Recommendation of Minimum Standard Reporting Criteria

Lack of reporting consistency is common in randomized controlled trials (RCTs) in critical care nutrition. This impacts synthesis and interpretation and may misinform clinical practice. The objective was to evaluate reporting of parallel-group RCTs of enteral or parenteral nutrition interventions in critically ill adults against the recommendations in the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines and a priori-defined nutrition criteria. A systematic search of CENTRAL, MEDLINE, EMBASE, and CINAHL was conducted to identify RCTs published from January 2011 to February 14, 2020. The primary outcome was the percentage of CONSORT criteria "completely met" (a score of 1) from all included studies (out of a total possible score of 37). Secondary outcomes included the percentage of CONSORT criteria that were "partially" or "not met" and the percentage of a priori-defined nutrition criteria that were "completely," "partially," or "not met" (adjusted to reflect criteria applicable to the paper). Data are presented as mean (standard deviation). Comparisons of normally distributed continuous data were made using a t-test (P < .05). Of 18,969 articles identified, 56 studies met inclusion criteria. Of these, 60% (19%) of the eligible CONSORT criteria were "completely met," 20% (9%) "partially met," and 20% (15%) "not met." For the nutrition criteria, 41% (20%) of the eligible criteria were "completely met," 25% (14%) "partially met," and 34% (17%) "not met." Reporting against CONSORT guidelines was variable and often incomplete in relation to important a priori-defined nutrition variables.

Association between serum lactate levels and enteral feeding intolerance in septic patients treated with vasopressors: a retrospective cohort study

Background

To assess the association between serum lactate levels and intolerance to enteral nutrition (EN) in septic patients treated with vasopressors.

Methods

This retrospective study was conducted between January 1, 2015 and May 1, 2018 in an intensive care unit (ICU). Patients with sepsis who were given EN and treated with vasopressors were included. EmpowerStats software and R (version 3.3.2) was used to examine the association between serum lactate levels and intolerance to EN.

Results

Among the 132 septic patients (age, 60.6±18.1 years) enrolled, 35 (26.5%) patients suffered intolerance to EN. Multiple logistic regression analysis demonstrated that an elevated lactate level was an independent risk factor for EN intolerance [odds ratio (OR): 2.7; 95% confidence interval (CI): 1.6–4.4; P<0.001]. The area under the receiver operating characteristic (ROC) curve for serum lactate levels was 0.764 (95% CI: 0.664–0.864). Stratified analysis suggested that age was the most prominent interactive factor for serum lactate levels in EN intolerance. Serum lactate levels were closely correlated to EN intolerance in elderly patients (age ≥65 years) (OR: 9.5; 95% CI: 2.1–42.4; P=0.0261 for interaction), while no such association was identified in younger patients (age <65 years; OR: 1.7; 95% CI: 1.0–2.9; P=0.052).

Conclusions

Serum lactate levels were associated with an increased risk of EN intolerance in patients with sepsis, especially in elderly individuals. An elevated serum lactate level may be an early predictor of EN intolerance in elderly septic patients treated with vasopressors. However, further studies are called for to verify these findings.

Safety of Early Enteral Nutrition for Cardiac Medical Critically Ill Patients - A Retrospective Observational Study

Background: Early intervention with enteral nutrition (EN) is the standard of care in many medical intensive care units (ICUs). However, few studies have addressed the use of early EN for critically ill patients in the cardiac ICU (CICU). In this study we explored the indications for early EN for patients admitted to a CICU. Methods and Results: This retrospective observational study included 63 consecutive patients admitted to the CICU who were diagnosed with cardiovascular disease. Early EN was initiated in these patients as per the hospital's nutrition protocol. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at admission were 18.8 and 9.1, respectively. All patients were admitted to the medical CICU with a diagnosis of cardiovascular disease and/or cardiopulmonary arrest. Enteral feeding was initiated in 59 patients (94%) within 5 days of admission. Fifty-two patients (83%) achieved the energy intake goal at Day 7 of their CICU admission either by enteral feeding or oral intake; 49 patients (78%) survived to time of discharge. The patients experienced several minor complications, including minor reflux (4 patients; 6%) and diarrhea (8 patients; 13%). None of the patients developed aspiration pneumonia or bowel ischemia. Conclusions: The present retrospective observational study indicates that early EN for critically ill patients in a medical CICU can be achieved safely with no major complications.

Is Energy Delivery Guided by Indirect Calorimetry Associated With Improved Clinical Outcomes in Critically Ill Patients? A Systematic Review and Meta-analysis

Background:

Indirect calorimetry (IC) is recommended to guide energy delivery over predictive equations in critical illness due to its precision. However, the impact of using IC to measure energy expenditure on clinical outcomes is uncertain.

Objective:

To evaluate whether using IC to measure energy expenditure to inform energy delivery reduced hospital mortality and improved other important outcomes compared to using predictive equations in critically ill adults.

Methods:

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Medline, Embase, CINAHL, and the Cochrane Library were searched for studies using IC to guide energy delivery compared to a predictive equation in adult critically ill patients with the primary outcome (hospital mortality) or any of the secondary outcomes reported (including but not limited to hospital and intensive care unit (ICU) length of stay (LOS) and duration mechanical ventilation (MV). Risk of bias within studies was assessed using the Cochrane “Risk of Bias” 1 tool. Random-effect meta-analyses were used when heterogeneity between studies existed (I² > 50%). Data are reported as median (interquartile range [IQR]), binomial outcomes as odds ratio (OR), 95% confidence interval (CI), and continuous outcomes as mean difference (MD).

Results:

Of 4060 articles, 4 randomized controlled trials were identified with 396 patients included in analysis. Three studies were considered low risk of bias and 1 as high risk. Two studies reported hospital mortality (n = 130 and 40 participants, respectively). When combined, no association between IC-guided energy delivery and hospital mortality was found (OR = 0.81, 95% CI = [0.25, 2.67], P = 0.73, I² = 52). No differences were reported with ICU mortality and hospital LOS between groups, but ICU LOS and duration of MV varied across all studies. According to the meta-analysis, no differences were observed in ICU LOS (MD = 1.39, 95% CI = [–5.01, 7.79], P = 0.67, I² = 81%), although the duration of MV was increased when energy delivery was guided by IC (MD = 2.01, 95% CI = [0.45, 3.57], P = 0.01, I² = 26%). In all 4 studies, prescribed energy targets were more closely met when energy delivery was informed by IC compared to a predictive equation. Three studies reported the percentage delivered versus the prescribed energy target, with the median (IQR) delta between the IC and predictive equation arms 19% (10%-32%).

Conclusion:

Limited data exist to assess the impact of using IC to inform energy delivery in comparison to predictive equations on hospital mortality. The association of IC use with other important outcomes, including duration of MV, needs to be further explored before definitive conclusions can be made.

Medical Nutrition Therapy in Critically Ill Patients Treated on Intensive and Intermediate Care Units: A Literature Review

Medical nutrition therapy in critically ill patients remains challenging, not only because of the pronounced stress response with a higher risk for complications, but also due to their heterogeneity evolving from different phases of illness. The present review aims to address current knowledge and guidelines in order to summarize how they can be best implemented into daily clinical practice. Further studies are urgently needed to answer such important questions as best timing, route, dose, and composition of medical nutrition therapy for critically ill patients and to determine how to assess and to adapt to patients’ individual needs.

Pancreatic Cancer Cachexia: The Role of Nutritional Interventions

Pancreatic cancer is a cancer with one of the highest mortality rates and many pancreatic cancer patients present with cachexia at diagnosis. The definition of cancer cachexia is not consistently applied in the clinic or across studies. In general, it is “defined as a multifactorial syndrome characterised by an ongoing loss of skeletal muscle mass with or without loss of fat mass that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.” Many regard cancer cachexia as being resistant to dietary interventions. Cachexia is associated with a negative impact on survival and quality of life. In this article, we outline some of the mechanisms of pancreatic cancer cachexia and discuss nutritional interventions to support the management of pancreatic cancer cachexia. Cachexia is driven by a combination of reduced appetite leading to reduced calorie intake, increased metabolism, and systemic inflammation driven by a combination of host cytokines and tumour derived factors. The ketogenic diet showed promising results, but these are yet to be confirmed in human clinical trials over the long-term. L-carnitine supplementation showed improved quality of life and an increase in lean body mass. As a first step towards preventing and managing pancreatic cancer cachexia, nutritional support should be provided through counselling and the provision of oral nutritional supplements to prevent and minimise loss of lean body mass.

The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

The effect of enteral versus parenteral nutrition for critically ill patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To analyze the effect of enteral nutrition compared with parenteral nutrition in critically ill patients.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

SETTING

Intensive care unit.

PATIENTS

23 trials containing 6478 patients met our inclusion criteria.

INTERVENTION

A systematical literature search was conducted to identify eligible trials in electronic databases including PubMed, Embase, Scopus, EBSCO and Cochrane Library. The primary outcome was mortality, the secondary outcomes were gastrointestinal complications, bloodstream infections, organ failures, length of stay in ICU and hospital. We performed a predefined subgroup analyses to explore the treatment effect by mean age, publication date and disease types.

MAIN RESULTS

The result showed no significant effect on overall mortality rate (OR 0.98, 95%CI 0.81 to 1.18, P = 0.83, I² = 19%) and organ failure rate (OR 0.87, 95%CI 0.75 to 1.01, P = 0.06, I² = 16%). The use of EN had more beneficial effects with fewer bloodstream infections when compared to PN (OR 0.59, 95%CI 0.43 to 0.82, P = 0.001, I² = 27%) and this was more noteworthy in the subgroup analysis for critical surgical patients (OR 0.36, 95%CI 0.22 to 0.59, P < 0.0001, I² = 0%). EN was associated with reduction in hospital LOS (MD -0.90, 95%CI -1.63 to -0.17, P = 0.21, I² = 0%) but had an increase incidence of gastrointestinal complications (OR 2.00, 95%CI 1.76 to 2.27, P < 0.00001, I² = 0%).

CONCLUSION

For critically ill patients, the two routes of nutrition support had no different effect on mortality rate. The use of EN could decrease the incidence of bloodstream infections and reduce hospital LOS but was associated with increased risk of gastrointestinal complications.

Comment je prends en charge la nutrition d’un patient en état de choc

La réponse métabolique à l’agression correspond à un ensemble de réactions à la base de l’adaptation de l’organisme aux nouvelles conditions. Ces modifications concernent des aspects métaboliques spécifiques comme le maintien de la masse protéique et/ou l’état des réserves énergétiques. L’une des principales difficultés de l’optimisation du support métabolique consiste à distinguer les changements métaboliques bénéfiques de ceux qui sont délétères pour l’organisme. Dans ce contexte, les objectifs thérapeutiques peuvent se limiter à une approche nutritionnelle s’attachant à limiter le déficit énergétique et les pertes protéiques et musculaires. Ils peuvent être plus ambitieux en essayant d’adapter les apports aux différents besoins d’un point de vue quantitatif comme qualitatif. La limitation du déficit énergétique semble être un objectif raisonnable à atteindre selon les données de la littérature. Enfin, essayer d’interférer avec la réponse métabolique à l’agression (immunomodulation, manipulations pharmacologiques des voies métaboliques, etc.) représente le degré d’intervention métabolique le plus élaboré et, si quelques données ont pu être encourageantes, il n’est pas possible d’affirmer que cet objectif soit complètement réaliste, voire même bénéfique. Les apports nutritionnels doivent être intégrés à la stratégie thérapeutique globale de prise en charge. La réponse optimale du support nutritionnel a pour but « de donner les moyens métaboliques » de la guérison.

Effect of combined parenteral and enteral nutrition versus enteral nutrition alone for critically ill patients: A systematic review and meta-analysis

BACKGROUND AND AIM

The increased mortality rate and other poor prognosis make malnutrition a serious issue for adult critically ill patients in intensive care unit care. This study was to compare outcomes between combined parenteral and enteral nutrition and enteral nutrition alone for adult critically ill patients.

MATERIALS AND METHODS

The PubMed (June 30, 2018), EMBASE (June 30, 2018), and Cochrane library databases (June 30, 2018) were searched systematically. Randomized controlled trials (RCTs) of comparing combined PN and EN with EN alone were eligible. Relative risks (RRs), mean differences (MDs), and 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes.

RESULTS

Eight RCTs involving 5360 patients met the inclusion criteria. Compared with combined PN and EN, fewer respiratory infections (RR, 1.13 [95% CI 1.01-1.25]) and shorter length of days at hospital (MD, 1.83 [95% CI 1.05-2.62]) were observed in EN alone group. And no significant differences were found on hospital mortality (RR, 0.91 [95% CI 0.74-1.12]), length of days in ICU (MD, -0.23 [95% CI -1.79 to 1.32]), duration of ventilatory support (MD, -1.10 [95% CI -3.15 to 0.94]), albumin (MD, -0.04 [95% CI, -0.12 to 0.21]), or prealbumin (MD, -0.77 [95% CI -0.22 to 1.75]) between theses 2 groups.

CONCLUSION

Receiving EN alone decreased the respiratory infections and length of days at hospital for critically ill patients. Combined PN and EN did not add up the potential risk from PN and EN on hospital mortality, length of days in ICU, duration of ventilatory support, albumin, and prealbumin.

Gastric residual volume measurement in the intensive care unit: an international survey reporting nursing practice

BACKGROUND

Gastric residual volume measurement is routinely used to evaluate the feeding tolerance and gastro-oesophageal reflux in patients receiving enteral feeding therapy in the intensive care unit. However, little supportive evidence for this intervention is available as the usefulness of gastric residual volume measurements in patients receiving enteral feeding therapy in the intensive care is controversial.

AIM

The aim of this study was to assess the practice of intensive care unit nurses related to gastric residual volume measurement in patients receiving enteral nutrition.

METHODS

A survey was conducted among a sample of intensive care unit nurses (n = 832) from four hospitals in Turkey (n = 182) and attendees of the Annual Congress of the Flemish Society for Critical Care Nurses in Flanders, Belgium (n = 650). The survey instrument was developed by the researchers based on the related literature.

RESULTS

A total of 480 nurses completed the questionnaire (response rate = 73%). Gastric residual volume is measured by 98·0% of respondents, with wide variations in the frequency of measuring. A 50-200 mL gastric residual volume is considered problematic by 45·5% (n = 183) of the participants, and only 18·4% (n = 81) reported their practice to be based on a current guideline. Strikingly, more experienced intensive care unit nurses appear to perform gastric residual volume measurements more commonly than their less experienced colleagues (p = 0·004), while the practice is more often reported to be performed in Belgium than in Turkey (p < 0·001).

CONCLUSION

Gastric residual volume management could be improved by applying current evidence to daily nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Our results show that increased awareness of these guidelines by nurses is needed to reduce inefficient use of working time and resources, streamline clinical practices and improve patient outcomes. Current gastric residual volume measurement guidelines and up-to-date, relevant training should be provided to nurses.

Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit

BACKGROUND

Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition.

OBJECTIVES

To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews.

SELECTION CRITERIA

We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE.

MAIN RESULTS

We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients&rsquo; mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

Recent advances of medical foods in China: The opportunities and challenges under standardization

Malnutrition with high incidence in hospitalized patients in China has brought a significant burden of disease. Although many clinical studies have demonstrated the importance of nutritional for patients with malnutrition, the application of medical foods in China is still restricted. For the classification, limits, production and registration of medical foods, the Chinese government newly enacted a series of regulations. In this review, comparing the policy, researches, and product variety of medical foods in China with other countries, although the current status of the development of medical foods in China is still far behind that of developed countries, some of regulations are stricter than those of many other countries or organizations. The medical foods in China are divided into four categories, the nutrients and environmental contaminants are limited to ensure the safety. As a prospect, the development of medical foods in China is expected to get out of the predicament of lack of emphasis, shortage of supply, backward of local processing technology and the imperfect management system. After all, in view of the huge population and the increasing demand of nutrition in China, there must be a very good prospect for the future development of the medical foods industry in China.

Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

BACKGROUND

Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition.

METHODS

In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099.

FINDINGS

After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04).

INTERPRETATION

In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition.

FUNDING

La Roche-sur-Yon Departmental Hospital and French Ministry of Health.

Early Enteral Nutrition is Associated with Faster Post-Esophagectomy Recovery in Chinese Esophageal Cancer Patients: A Retrospective Cohort Study

We retrospectively examined a large cohort of esophageal carcinoma patients who received early enteral nutrition (EEN) to clarify the validity of EEN compared with total parenteral nutrition (TPN). Included were a total of 665 consecutive patients with histologically confirmed carcinoma of the esophagus or esophagogastric junction; and all patients underwent esophagectomy. The patients were divided into two groups: TPN (n = 262) and EEN (n = 403). The TPN group consisted of patients who only received intravenous nutrition support after operation. The postoperative length of hospital stay (PLOS), anastomotic leakage, mortality after surgery, and hospital charges were reviewed and analyzed. Compared with the TPN group, the EEN group had significantly shorter mean PLOS (15.6 days vs. 22.5 days; P < 0.01). Multivariable linear regression analysis revealed EEN to be associated with shorter PLOS even after adjustment for tumor histology, tumor location, type of esophagectomy, and postoperative albumin infusion. Hospital charges were also significantly less for those in the EEN group than the TPN group. There was no significant difference between the two groups regarding the complication of anastomotic leakage and clinical outcome after surgery. These findings suggest that EEN reduces PLOS and hospital charges of Chinese esophageal cancer patients who had an esophagectomy.

Enteral Nutrients and Gastrointestinal Physiology

The gastrointestinal (GI) tract is a highly efficient organ system with specialized structures to facilitate digestion and absorption of nutrients to meet the body's needs. The presence of nutrients in the GI tract supports optimal structure and function, stimulates regulatory hormones, and supports the microbiota, the population of microorganisms residing in the GI tract. A lack of enteral nutrition (EN) results in impaired GI integrity and serious patient complications, making EN a priority. Normal GI physiology is reviewed, and the regulatory impact of luminal nutrients on GI function is discussed.

Initial nutritional management during noninvasive ventilation and outcomes: a retrospective cohort study

Background

Patients starting noninvasive ventilation (NIV) to treat acute respiratory failure are often unable to eat and therefore remain in the fasting state or receive nutritional support. Maintaining a good nutritional status has been reported to improve patient outcomes. In the present study, our primary objective was to describe the nutritional management of patients starting first-line NIV, and our secondary objectives were to assess potential associations between nutritional management and outcomes.

Methods

Observational retrospective cohort study of a prospective database fed by 20 French intensive care units. Adult medical patients receiving NIV for more than 2 consecutive days were included and divided into four groups on the basis of nutritional support received during the first 2 days of NIV: no nutrition, enteral nutrition, parenteral nutrition only, and oral nutrition only.

Results

Of the 16,594 patients admitted during the study period, 1075 met the inclusion criteria; of these, 622 (57.9%) received no nutrition, 28 (2.6%) received enteral nutrition, 74 (6.9%) received parenteral nutrition only, and 351 (32.7%) received oral nutrition only. After adjustment for confounders, enteral nutrition (vs. no nutrition) was associated with higher 28-day mortality (adjusted HR, 2.3; 95% CI, 1.2–4.4) and invasive mechanical ventilation needs (adjusted HR, 2.1; 95% CI, 1.1–4.2), as well as with fewer ventilator-free days by day 28 (adjusted relative risk, 0.7; 95% CI, 0.5–0.9).

Conclusions

Nearly three-fifths of patients receiving NIV fasted for the first 2 days. Lack of feeding or underfeeding was not associated with mortality. The optimal route of nutrition for these patients needs to be investigated.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1867-y) contains supplementary material, which is available to authorized users.

Delivery of full predicted energy from nutrition and the effect on mortality in critically ill adults: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The amount of energy required to improve clinical outcomes in critically ill adults is unknown.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the impact of near target energy delivery to critically ill adults on mortality and other clinically relevant outcomes.

DESIGN

Following PRISMA guidelines, MEDLINE, EMBASE, CINHAL and the Cochrane Library were searched for randomised controlled trials evaluating nutrition interventions in adult critical care populations. Included studies compared delivery of ≥80% of predicted energy requirements (near target) from enteral and/or parenteral nutrition to <80% (standard care) and reported mortality. The quality of individual studies was assessed using the Cochrane 'Risk of Bias' tool, and the overall body of evidence using the GRADE approach. Fixed or random effect meta-analyses were used pending the presence of heterogeneity (I² > 50%) when 3 or more studies reported the same outcome. Outcomes are presented as risk ratio (RR), 95% confidence interval (CI).

RESULTS

Ten trials with 3155 participants were included. Mortality was unaffected by the intervention (RR 1.02, 95% CI 0.81, 1.27, p = 0.89, I² = 25%). Evaluation of studies of higher quality and low risk of bias did not alter the mortality inference (3 trials, 352 participants, RR 0.83, 95% CI 0.49, 1.40, p = 0.19, I² = 39%). The quality of evidence across outcomes was very low.

CONCLUSIONS

The delivery of near target energy when compared to standard care in adult critically ill patients was not associated with an effect on mortality. Because the quality of the evidence across outcomes was very low there is considerable uncertainty surrounding this estimate. This has implications for clinical utility of the evidence within the included reviews.

Critical Care Nutrition: Where's the Evidence?

The surgical critically ill patient is subject to a variable and complex metabolic response, which has detrimental effects on immunity, wound healing, and preservation of lean body muscle. The concept of nutrition support has evolved into nutrition therapy, whereby the primary objectives are to prevent oxidative cell injury, modulate the immune response, and attenuate the metabolic response. This review outlines the metabolic response to critical illness, describes nutritional risk; reviews the evidence for the role, dose, and timing of enteral and parenteral nutrition, and reviews the evidence for immunonutrition in the surgical intensive care unit.

Effects on nutritional care practice after implementation of a flow chart-based nutrition support protocol in an intensive care unit

Background

Enteral nutrition (EN) is associated with improved outcome in critically ill patients and is more affordable. We compared nutritional care practice in our ICU before and after modification of our nutrition support protocol: Several comprehensive documents were substituted with one flow chart and early EN was encouraged.

Design

Retrospective observational study.

Methods

Nutritional data were collected from admission up to 7 days in 25 patients before and 25 patients after protocol modification.

Results

The percentage of patients receiving EN within 72 hr of admission increased from 64% before to 88% after protocol modification. Cumulative percentage energy from EN during ICU days 1–4 increased from 26–89% of total kcal. Overall amount of nutrition administered enterally increased, with a corresponding marked decline in use of parenteral nutrition. Pre‐modification, >80% of patients received >65% of their calculated nutrition requirements by ICU Day 4; post‐modification this goal was achieved by Day 7.

Lipids in the intensive care unit: Recommendations from the ESPEN Expert Group

This article summarizes the presentations given at an ESPEN Workshop on "Lipids in the ICU" held in Tel Aviv, Israel in November 2014 and subsequent discussions and updates. Lipids are an important component of enteral and parenteral nutrition support and provide essential fatty acids, a concentrated source of calories and building blocks for cell membranes. Whilst linoleic acid-rich vegetable oil-based enteral and parenteral nutrition is still widely used, newer lipid components such as medium-chain triglycerides and olive oil are safe and well tolerated. Fish oil (FO)-enriched enteral and parenteral nutrition appears to be well tolerated and confers additional clinical benefits, particularly in surgical patients, due to its anti-inflammatory and immune-modulating effects. Whilst the evidence base is not conclusive, there appears to be a potential for FO-enriched nutrition, particularly administered peri-operatively, to reduce the rate of complications and intensive care unit (ICU) and hospital stay in surgical ICU patients. The evidence for FO-enriched nutrition in non-surgical ICU patients is less clear regarding its clinical benefits and additional, well-designed large-scale clinical trials need to be conducted in this area. The ESPEN Expert Group supports the use of olive oil and FO in nutrition support in surgical and non-surgical ICU patients but considers that further research is required to provide a more robust evidence base.

Significant Published Articles for Pharmacy Nutrition Support Practice in 2016

Purpose: To assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2016 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the paper was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not scored, were also included. Results: A total of 103 articles were identified; 10 from the primary literature were voted by the group to be of high importance. An additional 11 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists, engaged in nutrition support therapy, be familiar with the majority of these articles as it pertains to their practice.

Prevention and Therapy of Acute Kidney Injury in the Developing World

Timely recognition of patients at risk or with possible acute kidney injury (AKI) is essential for early intervention to minimize further damage and improve outcome. Initial management of patients with suspected and persistent AKI should include thorough clinical assessment of all patients with AKI to identify reversible factors, including fluid volume status, potential nephrotoxins, and an assessment of the underlying health of the kidney. Based on these assessments, early interventions to provide appropriate and adequate fluid resuscitation while avoiding fluid overload, removal of nephrotoxins, and adjustment of drug doses according to the level of kidney function derangement are important. The judicious use of diuretics for fluid overload and/or in cardiac decompensated patients and introduction of early enteral nutritional support need to be considered to improve outcomes in AKI. Although these basic principles are well recognized, their application in clinical practice in low resource settings is often limited due to lack of education, availability of resources, and lack of trained personnel, which limits access to care. We report the consensus recommendations of the 18th Acute Dialysis Quality Initiative meeting in Hyderabad, India, on strategies to evaluate patients with suspected AKI and initiate measures for prevention and management to improve outcomes, particularly in low resource settings. These recomendations provide a framework for caregivers, who are often primary care physicians, nurses, and other allied healthcare personnel, to manage patients with AKI in resource poor countries.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

BACKGROUND

Malnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.

OBJECTIVES

To estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.

DESIGN

A pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.

SETTING

Adult general critical care units in 33 NHS hospitals in England.

PARTICIPANTS

2400 eligible patients.

INTERVENTIONS

Five days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.

MAIN OUTCOME MEASURES

All-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.

RESULTS

By 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) -2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at -£1320 (95% CI -£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective - given the data - is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.

LIMITATIONS

Blinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.

CONCLUSIONS

There was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.

FUTURE WORK

Nutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17386141.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.