Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

New application of intestinal obstruction catheter in enterocutaneous fistula: A case report

BACKGROUND

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin. ECF can lead to massive body fluid loss, hypercatabolism, and malnutrition. Therefore, nutritional support plays a crucial role in managing ECFs and promoting the healing of fistulas. For nutritional support, enteral nutrition (EN) is the preferred method when gastrointestinal function is recovering. Currently, various EN approaches have been applied for different anatomical positions of the ECF. However, the effectiveness of administering EN support for treating lower ECFs still needs further exploration and improvement.

CASE SUMMARY

We present the case of a 46-year-old male who underwent gastrointestinal stromal tumour resection. Six days after the surgery, the patient presented with fever, fatigue, severe upper abdominal pain, and septic shock. Subsequently, lower ECFs were diagnosed through laboratory and imaging examinations. In addition to symptomatic treatment for homeostasis, total parenteral nutrition support was administered in the first 72 h due to dysfunction of the intestine. After that, we gradually provided EN support through the intestinal obstruction catheter in consideration of the specific anatomic position of the fistula instead of using the nasal jejunal tube. Ultimately, the patient could receive optimal EN support via the catheter, and no complications were found during the treatment.

CONCLUSION

Nutritional support is a crucial element in ECF management, and intestinal obstruction catheters could be used for early EN administration.

Associations between enteral nutrition and outcomes in the SUP-ICU trial: Results of exploratory post hoc analyses

BACKGROUND

Enteral nutrition may affect risks of gastrointestinal bleeding, pneumonia and mortality in critically ill patients and may also modify the effects of pharmacological stress ulcer prophylaxis. We undertook post hoc analyses of the stress ulcer prophylaxis in the intensive care unit trial to assess for any associations and interactions between enteral nutrition and pantoprazole.

METHODS

Extended Cox models with time-varying co-variates and competing events were used to assess potential associations, adjusted for baseline severity of illness. Potential interactions between daily enteral nutrition and allocation to pantoprazole on outcomes were similarly assessed.

RESULTS

Enteral nutrition was associated with lower risk of clinically important gastrointestinal bleeding (cause-specific hazard ratio [HR]: 0.29, 95% confidence interval: [CI] 0.19-0.44, p < .001), higher risk of pneumonia (HR: 1.44, 95% CI: 1.14-1.82, p = .003), and lower risk of all-cause mortality (HR: 0.22, 95% CI: 0.18-0.27, p < .001). Enteral nutrition with allocation to pantoprazole was associated with a lower risk of mortality (HR: 0.27, 95% CI: 0.21-0.35, p < .001), similar to enteral nutrition with allocation to placebo (HR: 0.17, 95% CI: 0.13-0.23, p < .001). Allocation to pantoprazole with no enteral nutrition had little effect on mortality (HR: 0.83, 95% CI: 0.63-1.09, p = .179), whilst allocation to pantoprazole and receipt of enteral nutrition was mostly compatible with increased all-cause mortality (HR: 1.27, 95% CI: 0.99-1.64, p = .061). The test of interaction between enteral nutrition and pantoprazole treatment allocation for all-cause mortality was statistically significant (p = .024).

CONCLUSIONS

Enteral nutrition was associated with an increased risk of pneumonia and a reduced risk of gastrointestinal bleeding. The interaction between pantoprazole and enteral nutrition suggesting an increased risk of mortality requires further study.

When can we start early enteral nutrition safely in patients with shock on vasopressors?

Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.

Review article: Evaluation and care of the critically ill patient with cirrhosis

BACKGROUND

The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients.

AIM

Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care.

METHODS

We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care.

RESULTS

Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource.

CONCLUSIONS

Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.

Nutritional support team intervention in surgical ICUs and its effect on nutrition delivery and quality in critically ill patients

RATIONAL

Critically ill surgical patients pose one of the greatest challenges in achieving nutritional goals. Several published papers have demonstrated clear benefits when nutrition support (NS) is managed by a multidisciplinary nutrition support team (NST). We hypothesized that implementing a NST in a surgical intensive care unit (ICU) would increase the number of patients achieving their nutritional goals.

MATERIAL AND METHOD

Multicenter "BEFORE & AFTER" study. In the BEFORE phase, an audit of the previous state of NS was conducted in three ICUs without a NST.

INTERVENTION

Implementation of a NST and protocol. In the AFTER phase, a new audit of NS was conducted. Continuous variables (presented as mean ± SD or median Q1-Q3) were tested using the t-test and Mann-Whitney U test. Categorical variables (presented as frequencies and percentages) were assessed using the chi-square test. A binomial logistic regression model was performed, with independent variables introduced using a stepwise forward method. A difference was considered to be significant with a two-sided P-value <0.05. Statistical analysis was conducted using IBM-SPSS 26.

RESULTS

A total of 83 patients were included in the BEFORE phase, and 85 in the AFTER phase. The latter group showed a higher frequency of nutritional risk and malnutrition (SGA B+C odds ratio 2.314, 95% CI 1.164-4.600). Laparoscopy was more frequently utilized as a surgical technique in the AFTER phase. No differences were observed in ICU and hospital LOS or 90 days' survival rates. Two variables remained independent factors to predict NS achievement: NST implementation (odds ratio 3.582, 95% CI 1.733-7.404), and surgical technique (odds ratio 3.231, 95% CI 1.312-7.959).

CONCLUSION

NST positively impacts the chance of achieving NS goals in critically ill surgical patients.

[Nutrition (therapy) in gastrointestinal failure]

BACKGROUND

The presence of gastrointestinal dysfunction is an outcome-relevant complication in critically ill ICU patients.

AIMS, MATERIALS AND METHODS

The following review aims to show the importance of gastrointestinal dysfunction. Multimodal therapy for gastroparesis and paralytic ileus is discussed.

CONCLUSION

Erythromycin and metoclopramide are options for gastroparesis, while neostigmine is commonly used for paralytic ileus.

Trophic Nutrition in ICU Patients Undergoing High-Flow Oxygen Therapy and/or Noninvasive Mechanical Ventilation: The Nutri-Trophic Study

Enteral nutrition (EN) therapy in ICU patients requiring oxygen therapy with high-flow nasal cannula (HFNC) and/or noninvasive mechanical ventilation (NIMV) is controversial. A prospective, cohort, observational, and multicenter study was conducted in 10 ICUs in Spain to analyze the 90-day mortality, tolerance, side effects, and infectious complications of trophic EN in patients requiring HFNC therapy and/or NIVM. A total of 149 patients were enrolled. The mean age, severity scores, tracheobronchitis, bacteremia, and antimicrobial therapy were significantly higher in deceased than in living patients (p < 0.05), and the mortality rate was 14.8%. A total of 110 patients received oral trophic feedings, 36 patients received nasogastric tube feedings (NGFs), and 3 received mixed feedings. Trophic EN was discontinued in only ten (14.9%) patients because of feeding-related complications. The variables selected for the multivariate logistic regression on feeding discontinuation were SOFA upon admission (OR per unit = 1.461) and urea (OR per mg/dL = 1.029). There were no significant differences in the development of new infections according to the route of EN administration. Early trophic feeding administered to patients with acute respiratory failure requiring noninvasive ventilation is safe and feasible, and is associated with few dietary and infectious complications in a mortality, setting comparable to similar studies.

Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis

BACKGROUND

Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury. The study objective was to compare health outcomes between different immunonutrition formulas.

METHODS

Real-world data from October 2015 -February 2019 in the PINC AI™ Healthcare Database (formerly the Premier Healthcare Database) was reviewed for patients with an intensive care unit (ICU) stay and ≥3 days exclusive use of either higher L-arginine formula (HAF), or lower L-arginine formula (LAF). Multivariable generalized linear model regression was used to check associations between formulas and ICU length of stay.

RESULTS

3,284 patients (74.5% surgical) were included from 21 hospitals, with 2,525 receiving HAF and 759 LAF. Inpatient mortality (19.4%) and surgical site infections (6.2%) were similar across groups. Median hospital stay of 17 days (IQR: 16) did not differ by immunonutrition formula. Median ICU stay was shorter for patients receiving HAF compared to LAF (10 vs 12 days; P<0.001). After adjusting for demographics, visit, severity of illness, and other clinical characteristics, associated regression-adjusted ICU length of stay for patients in the HAF group was 11% shorter [0.89 (95% CI: 0.84, 0.94; P<0.001)] compared to patients in the LAF group. Estimated adjusted mean ICU length of stay was 9.4 days (95% CI: 8.9, 10.0 days) for the HAF group compared to 10.6 days (95% CI: 9.9, 11.3 days) for the LAF group (P<0.001).

CONCLUSIONS

Despite formulas being isocaloric and isoproteic, HAF use was associated with significantly reduced ICU length of stay, compared to LAF. Higher arginine immunonutrition formula may play a role in improving health outcomes in primarily surgical critically ill patients.

Analysis of risk factors and development of predictive model for malnutrition in patients with traumatic brain injury

Malnutrition is a highly prevalent complication in patients with traumatic brain injury (TBI), and it is closely related to the prognosis of patients. Accurate identification of patients at high risk of malnutrition is essential. Therefore, we analyzed the risk factors of malnutrition in patients with TBI and developed a model to predict the risk of malnutrition. A retrospective collection of 345 patients with TBI, and they were divided into malnutrition and comparison groups according to the occurrence of malnutrition. Univariate correlation and multifactor logistic regression analyses were performed to determine patients' malnutrition risk factors. We used univariate and logistic regression (forward stepwise method) analyses to identify significant predictors associated with malnutrition in patients with TBI and developed a predictive model for malnutrition prediction. The model's discrimination, calibration, and clinical utility were evaluated using the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA). A total of 216 patients (62.6%) developed malnutrition. Multifactorial logistic regression analysis showed that pulmonary infection, urinary tract infection, dysphagia, application of NGT, GCS score ≤ 8, and low ADL score were independent risk factors for malnutrition in patients with TBI (P < 0.05). The area under the curve of the model was 0.947. Calibration plots showed good discrimination of model calibration. DCA showed that the column line plot models were all clinically meaningful when nutritional interventions were performed over a considerable range of threshold probabilities (0-0.98). Malnutrition is widespread in patients with TBI, and the nomogram is a good predictor of whether patients develop malnutrition.

Nutrition therapy in critically ill patients with severe acute pancreatitis

A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.

An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit

Aim and background

Optimal feeding strategy for critically ill patients of intensive care unit (ICU) is often a matter of debate as patients admitted to ICU are highly catabolic and reduction in muscle mass is very common. We aimed at early achievement of nutritional goals in preventing skeletal muscle breakdown and improving clinical outcomes among critically ill patients with high risk of malnutrition.

Materials and methods

Nutrition risk in the critically ill (mNUTRIC) Score was used to identify the risk of malnutrition within 24 hours of admission. Quadriceps muscle mass index was measured within 24 hours of admission to ICU and repeated on 7th day. Enteral feeding was monitored by the nutrition expert as part of routine patient care and clinical outcomes were monitored.

Results

A total of 287 patients admitted in ICU were screened for malnutrition and 60 (20.9%) of them had high score (>5). There was no statistically significant reduction in the quadriceps muscle mass index (p < 0.05) (t = 0.601) measured within 24 hours of admission and on the 7th day of ICU stay, signifying that the nutritional prescription and monitoring may be useful in preserving the muscle mass. This study did not find statistically significant association between the high mNUTRIC score on admission and the clinical outcomes, such as 28 days mortality, incidence of pressure ulcers, length of ICU stay, and hospital-acquired infection (p > 0.05).

Conclusion

Early initiation and maintenance of enteral nutrition is essential for meeting target calories and protein requirements. It may help to preserve muscle mass in critically ill patients who are otherwise at high risk of malnutrition.

How to cite this article

Sharon T, Nayak SG, Shanbhag V, Hebbar S. An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit. Indian J Crit Care Med 2024;28(4):364-368.

Early enteral nutrition versus early supplemental parenteral nutrition in patients undergoing major abdominal surgery: a secondary analysis of 2 randomized clinical trials

BACKGROUND

The effect of early isoenergetic feeding routes [early enteral nutrition (E-EN) or early supplemental parenteral nutrition (E-SPN)] on the outcome of patients undergoing major abdominal surgery is controversial.

OBJECTIVES

The aim of this study was to investigate the impact of early isoenergetic EN compared with early isoenergetic SPN on nosocomial infections in patients undergoing major abdominal surgery.

METHODS

This study is a secondary, post hoc analysis of data from 2 open-label randomized clinical trials. Participants were recruited from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and with Nutritional Risk Screening 2002 score ≥3. All eligible patients were categorized into 2 groups based on their achievement of the 100% energy target on postoperative day (POD) 3: the E-EN group (n = 199) and the E-SPN group (n = 115). The primary outcome was the incidence of nosocomial infections between POD 3 and hospital discharge.

RESULTS

In total, 314 patients [mean (SD) age, 59.2 (11.4) y; 113 (36.0%) females] were included. Patients in the E-EN group showed no significant difference in nosocomial infections compared with those in the E-SPN group {17/199 [8.5%] compared with 10/115 [8.7%], risk difference, 0.2% [95% confidence interval (CI): -6.3, 6.6]}. The hematological nutritional status of the E-EN group showed a significant improvement at discharge compared with the E-SPN group (albumin: 38.0 ± 6.0 g/L compared with 35.5 ± 7.6 g/L; mean difference, -2.5 g/L; 95% CI: -4.0, -1.0 g/L; prealbumin: 200.0 ± 8.0 mg/L compared with 158.4 ± 38.1 mg/L; mean difference, -41.6 mg/L; 95% CI: -41.7, -36.1 mg/L). Other indicators were comparable between groups.

CONCLUSION

E-EN compared with isoenergetic SPN may not be associated with a reduced rate of nosocomial infection in patients undergoing major abdominal surgery, but may be associated with improved hematological nutritional status.

TRIAL REGISTRATION NUMBER

This trial was registered at clinicaltrials.gov as NCT03115957 (https://clinicaltrials.gov/ct2/show/NCT03115957) and NCT03117348 (https://clinicaltrials.gov/ct2/show/NCT03117348).

Early enteral nutrition and mobilization following head and neck surgery with free flap reconstruction

BACKGROUND

Perioperative management methods that reduce surgery-associated invasiveness and improve the quality of postoperative recovery are being promoted as enhanced recovery after surgery programs in various areas. Early enteral nutrition and mobilization are essential elements for enhanced recovery after surgery; however, their safety and feasibility are unclear in head and neck surgery with free tissue transfer reconstruction. This study aimed to clarify these uncertainties.

METHODS

This is a retrospective before-after study. From 2018 to 2022, 187 and 173 patients received conventional management on or before April 2020 and early management on or after May 2020, respectively. The conventional management and early management groups received enteral nutrition and mobilization on postoperative days 2 and 1, respectively. The primary outcome for safety assessment was the incidence of complications. The secondary outcome was the compliance rate of conventional management or early management for feasibility assessment and the length of hospital stay.

RESULTS

The clinical tumour-node-metastasis stage and American Society of Anesthesiologists physical status showed significant differences between the groups. In multivariable analysis, the early management group demonstrated a significantly lower incidence of treatment-required complication classified Clavien-Dindo Grade 2 and above (odds ratio = 0.57; 95% confidence interval = 0.31-0.92) and lower wound infection (odds ratio = 0.53; 95% confidence interval = 0.31-0.92). The early management group had lower compliance rate than the conventional management group; however, no statistically significant difference was observed (79.8% vs. 85.0%, P = 0.21).

CONCLUSION

Early management is safe and feasible following head and neck surgery with free tissue transfer reconstruction. It could reduce the complication rate and is considered a useful postoperative management method.

Application of a downward tract adherence method in the manual bedside placement of post-pyloric tubes in the intensive care unit

BACKGROUND

At present, there are few studies on the technical requirements of manual bedside placement of post-pyloric tube in Intensive Care Unit patients.

OBJECTIVE

To investigate the application value of downward tract adherence method in the manual bedside placement of jejunal tubes.

METHODS

In the downward group, 160 patients underwent manual bedside placement of jejunal tubes by a downward tract adherence method. In the conventional group, 144 patients were treated with conventional gas injection during the placement. The success rate, average time, and adverse reactions of the placement in the two groups were investigated and compared.

RESULTS

The success rate of the placement in the downward group was significantly higher (95% vs. 75%, P< 0.001) and the average time for the successful placement was shortened (23 ± 5.91 min vs. 26 ± 5.49 min, P= 0.025) than that in the conventional group. No treatment-related adverse reactions occurred in either group, and there were also no significant differences in vital sign changes.

CONCLUSIONS

The use of the downward tract adherence method in the manual bedside placement of postpyloric tubes for the intensive care patients at the bedside has a higher success rate, effectivity and safety.

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries

BACK GROUND

Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this study is to investigate serum lactate as a factor that can predict oral feeding tolerance and prolonged postoperative ileus (PPOI) in patients who underwent surgery for small bowel and/or mesenteric injury due to trauma.

METHODS

The single center retrospective observational study was conducted on 367 patients who underwent surgery for small bowel and/or mesenteric injury between January 2013 and July 2021. The patient group was divided into two groups based on whether the peak serum lactate was over 2mmol/L (18 mg/dL). In the group of lactate > 2mmol/L, it was divided into prolonged postoperative ileus (PPOI) groups and groups rather than PPOI.

RESULTS

Patients in the peak serum lactate > 2 group had tendency to use vasopressors, lower initial systolic blood pressure, larger number of packed red blood cells for 24 h, higher injury severity score, higher PPOI incidence, and a tendency for delayed oral intake tolerance. In peak serum lactate greater than 2 mmol/L group, the lactate normalization time (OR 1.699, p = 0.04), quantity of FFP transfusion for 24 h (OR 1.145, p = 0.012), and creatine kinase (OR 1.001, p = 0.023) were related to PPOI. The lactate normalization time had the highest correlation.

CONCLUSION

In patients undergoing surgical management for small bowel and/or mesenteric injury after trauma, serum lactate normalization time affects oral intake tolerance and prolongs postoperative ileus.

The future of artificial intelligence in clinical nutrition

PURPOSE OF REVIEW

Artificial intelligence has reached the clinical nutrition field. To perform personalized medicine, numerous tools can be used. In this review, we describe how the physician can utilize the growing healthcare databases to develop deep learning and machine learning algorithms, thus helping to improve screening, assessment, prediction of clinical events and outcomes related to clinical nutrition.

RECENT FINDINGS

Artificial intelligence can be applied to all the fields of clinical nutrition. Improving screening tools, identifying malnourished cancer patients or obesity using large databases has been achieved. In intensive care, machine learning has been able to predict enteral feeding intolerance, diarrhea, or refeeding hypophosphatemia. The outcome of patients with cancer can also be improved. Microbiota and metabolomics profiles are better integrated with the clinical condition using machine learning. However, ethical considerations and limitations of the use of artificial intelligence should be considered.

SUMMARY

Artificial intelligence is here to support the decision-making process of health professionals. Knowing not only its limitations but also its power will allow precision medicine in clinical nutrition as well as in the rest of the medical practice.

Octanoic acid-rich enteral nutrition attenuated hypercatabolism through the acylated ghrelin-POMC pathway in endotoxemic rats

OBJECTIVES

Metabolic disorders and no response to intravenous nutrition because of sepsis have been urgent problems for clinical nutrition support. Enteral nutrition (EN) has been an important clinical therapeutic measure in septic patients; however, simple EN has not demonstrated good performance. This study aimed to investigate the effects of different concentrations of octanoic acid (OA)-rich EN on hypercatabolism in endotoxemic rats and test whether OA-rich EN could attenuate hypercatabolism through the acylated ghrelin-proopiomelanocortin (POMC) pathway.

METHODS

Rats were randomly divided into six groups: sham, lipopolysaccharide (LPS), LPS + EN and LPS + EN + OA (0.25, 0.5, and 1 g/kg, respectively) groups to investigate the effects of different concentrations of OA-rich EN on hypercatabolism in endotoxemic rats. The rats were then randomly divided into four groups: sham, LPS, LPS + OA, and LPS + OA + Go-CoA-Tat, to test whether OA-rich EN attenuated hypercatabolism through the acylated ghrelin-POMC pathway. Rats received nutrition support via a gastric tube for 3 d (100 kcal/kg daily). Insulin resistance, muscle protein synthesis and atrophy, inflammatory cytokines, ghrelin in circulation and hypothalamus, ghrelin O-acyltransferase (GOAT), and the adenosine 5'-monophosphate-activated protein kinase (AMPK)-autophagy-POMC pathway were measured.

RESULTS

Compared with simple EN, OA-rich EN promoted the acylation of ghrelin in a dose-dependent manner and attenuated POMC-mediated hypercatabolism in endotoxemic rats. Inhibition of GOAT activity decreased the level of acylated ghrelin and aggravated POMC-mediated hypercatabolism conferred by OA-rich EN.

CONCLUSIONS

OA-rich EN could increase the level of acylated ghrelin and attenuate hypercatabolism through the acylated ghrelin-POMC pathway compared with simple EN in endotoxemic rats.

Physical and respiratory therapy in the critically ill patient with obesity: a narrative review

Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.

Glucose management in critically ill adults: A qualitative study from the experiences of health care providers

Aims and objective

To explain the components and elements of glucose management in critically ill adult patients from the healthcare providers' experiences.

Background

Critically ill adults are highly susceptible to stress-induced hyperglycaemia due to glucose metabolic disorders. Healthcare workers play a key role in the glycaemic management of critically ill patients. However, there is a lack of qualitative studies on the content and elements of glycaemic management and healthcare workers' perceptions about glycaemic management in China.

Design

Qualitative study that followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Methods

Individual semi-structured interviews were conducted from January to April 2022. Fifteen physicians and nurses were recruited from ten hospitals in mainland China. Data were analysed using inductive thematic analysis.

Results

Glucose management in critically ill adult patients from their experiences included two parts: the inner ring (practice behaviours) and the external space (methods and drivers). The practice behaviours of glucose management include five elements, while the methods and drivers of glucose management focus on three elements. The content covered under each element was identified.

Conclusion

This study developed a glycaemic management model for critically ill adult patients, clarified its elements based on the perceptions of healthcare providers and elaborated on the methods and drivers covered under each element to provide a reference for physicians and nurses to develop a comprehensive glycaemic management guideline for critically ill adult patients.

Relevance to clinical practice

Our study proposed a glucose management practice model for critically ill adult patients, and the elements and components included in this model can provide a reference for physicians and nurses when performing glucose management in critically ill patients.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Enteral nutrition practice in the prone position in patients with coronavirus disease 2019: An international one-day point prevalence analysis

BACKGROUND & AIMS

Enteral nutrition (EN) in the prone position for severe respiratory failure is considered possible with care. However, the extent to which it is feasible, especially its association with the length of intensive care unit (ICU) stay, is unclear. Therefore, we investigated the relationship between the duration of prone position therapy and adequacy of EN delivery and explored factors associated with this relationship in an observational study of critically ill patients with coronavirus disease 2019 (COVID-19) who were actively treated in the prone position.

METHODS

This study was a secondary analysis of a worldwide one-day prevalence study in the COVID-19 era. We investigated the care and nutritional therapy provided to critically ill patients with COVID-19 admitted to ICU, along with ICU-related information. We targeted patients who received only tube feeding and analyzed the relationship between the duration of prone position, length of ICU stays, and nutrition delivery via EN. In addition, a multivariate analysis was performed to examine factors affecting the achievement of EN delivery of 20 kcal/kg/day or more in patients who were placed in the prone position for at least 6 h.

RESULTS

A total of 399 patients who received only EN, excluding parenteral nutrition and oral intake, were included, of whom 58 % received EN energy delivery of ≥20 kcal/kg/day; this rate increased with the length of ICU stay, regardless of the duration of prone position. In a multivariate analysis of 121 patients who were in the prone position for at least 6 h, the presence of dedicated dietitians in the ICU (OR = 6.91, 95 % CI = 1.98 to 24.1, p < 0.01) was associated with a higher energy delivery. Conversely, the use of muscle relaxants (OR = 0.32, 95 % CI = 0.11 to 0.98, p = 0.04) and presence of nutrition protocols (OR = 0.24, 95 % CI = 0.07 to 0.77, p = 0.02) was associated with a lower energy delivery.

CONCLUSIONS

Patients with COVID-19 received adequate nutrition by EN even during prone position. Target EN delivery would be achieved with the introduction of prone position.

Crosstalk Between the Nervous System and Systemic Organs in Acute Brain Injury

Organ crosstalk is a complex biological communication between distal organs mediated via cellular, soluble, and neurohormonal actions, based on a two-way pathway. The communication between the central nervous system and peripheral organs involves nerves, endocrine, and immunity systems as well as the emotional and cognitive centers of the brain. Particularly, acute brain injury is complicated by neuroinflammation and neurodegeneration causing multiorgan inflammation, microbial dysbiosis, gastrointestinal dysfunction and dysmotility, liver dysfunction, acute kidney injury, and cardiac dysfunction. Organ crosstalk has become increasingly popular, although the information is still limited. The present narrative review provides an update on the crosstalk between the nervous system and systemic organs after acute brain injury. Future research might help to target this pathophysiological process, preventing the progression toward multiorgan dysfunction in critically ill patients with brain injury.

Development and validation of a postoperative bleeding complications prediction model in infective endocarditis

OBJECTIVES

Bleeding complications are one of the most serious postoperative complications after cardiac surgery and are associated with high mortality, especially in patients with infective endocarditis (IE). Our objectives were to identify the risk factors and develop a prediction model for postoperative bleeding complications in IE patients.

METHODS

The clinical data of IE patients treated from October 2013 to January 2022 were reviewed. Multivariate logistic regression analysis was used to evaluate independent risk factors for postoperative bleeding complications and develop a prediction model accordingly. The prediction model was verified in a temporal validation cohort. The performance of the model was evaluated in terms of its discrimination power, calibration, precision, and clinical utility.

RESULTS

A total of 423 consecutive patients with IE who underwent surgery were included in the final analysis, including 315 and 108 patients in the training cohort and validation cohort, respectively. Four variables were selected for developing a prediction model, including platelet counts, systolic blood pressure, heart failure and vegetations on the mitral and aortic valves. In the training cohort, the model exhibited excellent discrimination power (AUC = 0.883), calibration (Hosmer-Lemeshow test, P = 0.803), and precision (Brier score = 0.037). In addition, the model also demonstrated good discrimination power (AUC = 0.805), calibration (Hosmer-Lemeshow test, P = 0.413), and precision (Brier score = 0.067) in the validation cohort.

CONCLUSIONS

We developed and validated a promising risk model with good discrimination power, calibration, and precision for predicting postoperative bleeding complications in IE patients.

Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist

While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.

Combining proteins with n-3 PUFAs (EPA + DHA) and their inflammation pro-resolution mediators for preservation of skeletal muscle mass

The optimal feeding strategy for critically ill patients is still debated, but feeding must be adapted to individual patient needs. Critically ill patients are at risk of muscle catabolism, leading to loss of muscle mass and its consequent clinical impacts. Timing of introduction of feeding and protein targets have been explored in recent trials. These suggest that "moderate" protein provision (maximum 1.2 g/kg/day) is best during the initial stages of illness. Unresolved inflammation may be a key factor in driving muscle catabolism. The omega-3 (n-3) fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are substrates for synthesis of mediators termed specialized pro-resolving mediators or SPMs that actively resolve inflammation. There is evidence from other settings that high-dose oral EPA + DHA increases muscle protein synthesis, decreases muscle protein breakdown, and maintains muscle mass. SPMs may be responsible for some of these effects, especially upon muscle protein breakdown. Given these findings, provision of EPA and DHA as part of medical nutritional therapy in critically ill patients at risk of loss of muscle mass seems to be a strategy to prevent the persistence of inflammation and the related anabolic resistance and muscle loss.

ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

Navigating Nutritional Strategies: A Comprehensive Review of Early and Delayed Enteral Feeding in Acute Pancreatitis

This review critically examines enteral feeding strategies in managing acute pancreatitis, focusing on the contrasting early and delayed initiation approaches. Acute pancreatitis, marked by pancreatic inflammation, poses complex challenges, and nutritional interventions are pivotal in patient outcomes. Early enteral feeding, initiated within 24-48 hours, is associated with positive outcomes such as shortened hospital stays and reduced complications. However, controversies persist, with studies questioning its universal benefits. Conversely, delayed enteral feeding, employing a cautious approach, gains prominence in high-risk and severe cases. The identification of high-risk patients becomes paramount in decision-making. Practical recommendations for clinicians advocate an individualized approach, considering the severity of pancreatitis and regular monitoring. As the landscape of acute pancreatitis management evolves, staying abreast of emerging guidelines is essential. This review aims to provide a comprehensive understanding of critical findings, offering practical insights to guide clinicians in navigating the complexities of enteral feeding decisions in acute pancreatitis.

Esophago-Gastric Tube (EG Tube) in Debilitated Sea Turtle Rehabilitation: Insight in 195 Loggerheads Caretta caretta, Southern Italy

Efficient nutritional support plays a pivotal role in the rehabilitation of sea turtles, ensuring a positive, swift, and successful recovery from clinical conditions for their reintroduction into the wild. For sea turtles in severely emaciated and underweight condition, the primary objective is to facilitate weight gain in terms of both muscle mass and fat reserves. Traditionally, many sea turtle rehabilitators have employed the practice of force-feeding, which also involves the daily insertion of an orogastric tube from the mouth to the stomach. However, this technique may be highly stressful for the animals, carrying the risks of regurgitation and potential harm, requiring the removal of the animal from the water, and subjecting it to uncomfortable and potentially dangerous handling. The procedure may also involve risks for operators. In this study, we explore the utilization of a permanent esophago-gastric tube (EG tube) in sea turtles as an alternative to force-feeding, providing a respectful and appropriate approach to meeting the nutritional needs of patients. The administration of food, essential medications, and fluids is performed directly with the turtle in its tank, minimizing the stress associated with handling, while ensuring the safety of operators. The study involves 195 marine turtles that underwent surgery for the placement of a permanent EG tube between 2008 and 2022. Of these, 116 animals were treated at the Sea Turtle Clinic of the Department of Veterinary Medicine at the University of Bari, South Adriatic Sea, Puglia (IT), and 79 patients were admitted to the Sea Turtle Rescue Center of Lampedusa, Central Mediterranean Sea, Sicily (IT). The loggerhead turtles (Caretta caretta) required EG tube placement due to their poor condition related to various diseases, which were systematically categorized. The duration of EG tube placement was analyzed regarding the specific condition of the animals and the nature of their injuries, considering any complications or differences between the two facilities. The results of the study will provide valuable information for the ongoing care and treatment of marine turtles in rehabilitation facilities.

Survey on Nutrition in Neurological Intensive Care Units (SONNIC)-A Cross-Sectional Survey among German-Speaking Neurointensivists on Medical Nutritional Therapy

Medical nutritional therapy (MNT) in neurointensive care units (NICUs) is both particularly relevant and challenging due to prolonged analgosedation, immobilization, disorders of consciousness, and the high prevalence of dysphagia. Moreover, current guideline recommendations predominantly address the general intensive care unit (ICU) population, overlooking specific characteristics of neurological patients. We, therefore, conducted a web-based, cross-sectional survey for German-speaking neurointensivists mapping the clinical practices of MNT on NICUs to identify research gaps and common grounds for future clinical trials. A total of 25.9% (56/216) NICU representatives responded to our questionnaire. A total of 78.2% (43/55) were neurologist and 63% (34/54) held a leadership role. Overall, 80.4% (41/51) had established a standard operating procedure (SOP), largely based on the DGEM-Guideline (53.7%; 22/41), followed by the ESPEN-Guideline (14.6%; 6/41). Upon admission, 36% (18/50) conducted a risk stratification, with 83.3% primarily relying on past medical history (15/18) and clinical gestalt (15/18). Energy expenditure (EE) was measured or calculated by 75% (36/48), with 72.2% (26/36) using pragmatic weight-based equations. Indirect calorimetry was used by 19.4% (7/36). A total of 83.3% (30/36) used the patient's serum glucose level as the primary biomarker to monitor metabolic tolerance. SOPs regarding ICU-Acquired Weakness (ICUAW) were found in 8.9% (4/45) of respondents. Overall, guideline adherence was 47%. In summary, this is, to the best of our knowledge, the first study systematically describing the currently applied concepts of MNT on NICUs. The data reveal great variations in the implementation of guideline recommendations, indicating the need for further research and tailored approaches to optimize nutritional therapy in neurointensive care settings.

Enteral Nutrition in Critically Ill Patient With Septic Shock Requiring Vasopressor: Case Report

Nutritional support in critically ill patients is an essential aspect of treatment. In particular, the benefits of enteral nutrition (EN) are well recognized, and various guidelines recommend early EN within 48 hours in critically ill patients. However, there is still controversy regarding EN in critically ill patients with septic shock requiring vasopressors. Therefore, this case report aims to provide basic data for the safe and effective nutritional support in septic shock patients who require vasopressors. A 62-year-old male patient was admitted to the intensive care unit with a deep neck infection and mediastinitis that progressed to a septic condition. Mechanical ventilation was initiated after intubation due to progression of respiratory acidosis and deterioration of mental status, and severe hypotension required the initiation of norepinephrine. Due to hemodynamic instability, the patient was kept nil per os. Subsequently, trophic feeding was initiated at the time of norepinephrine dose tapering and was gradually increased to achieve 75% of the energy requirement through EN by the 7th day of enteral feeding initiation. Although there were signs of feeding intolerance during the increasing phase of EN, adjusting the rate of EN resolved the issue. This case report demonstrates the gradual progression and adherence to EN in septic shock patient requiring vasopressors, and the progression observed was relatively consistent with existing studies and guidelines. In the future, further case reports and continuous research will be deemed necessary for safe and effective nutritional support in critically ill patients with septic shock requiring vasopressors.

Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding

Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.

Construction of an enteral nutrition evaluation system for critically ill patients based on the Delphi method

BACKGROUND

This study aimed to construct an enteral nutrition evaluation system for critically ill patients using the Delphi method to direct the formulation of enteral nutrition support strategies and reduce interruption to enteral feeding.

METHODS

We used domestic and foreign databases to obtain and analyze the literature and form "The Whole-Proceeding Enteral Nutrition Evaluation System for Critically Ill Patients." The Delphi method was used to conduct two rounds of expert opinion consultation, combined with the suggestions from the research group to finalize the nutrition evaluation content of the system.

RESULTS

After two rounds of expert consultation, a nutrition evaluation system was formed around three dimensions: before the start, during, and after the end of nutritional support. The effective recovery rates of the two rounds of expert consultation were 90.0% (18/20) and 100.0% (18/18), respectively. Authority coefficients were 0.865 and 0.908, while Kendall coordination coefficients were 0.108 ( P < 0.05) and 0.115 ( P < 0.001), respectively. Finally, the full enteral nutrition evaluation system for critically ill patients was constructed based on the Delphi method, including three primary items and seven secondary and 28 tertiary indicators.

CONCLUSION

The established "Whole-Proceeding Enteral Nutrition Evaluation System for Critically Ill Patients" has high consistency from expert opinions and reliability, which can provide a practical evaluation tool for the process of enteral nutrition for severe patients.

[Guideline-conform treatment of sepsis]

The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.

[Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]

This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.

Enteral feeding tolerance during pharmacologic neuromuscular blockade

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Development and validation of a nomogram for predicting enteral feeding intolerance in critically ill patients (NOFI): Mixed retrospective and prospective cohort study

OBJECTIVE

Developing and validating a clinical prediction nomogram of enteral feeding intolerance (NOFI) in critically ill patients. So as to help clinicians implement pre-intervention for patients with high risk of enteral feeding intolerance (FI), formulate individualized feeding strategies, and reduce the probability of FI occurrence.

METHODS

From March 2018 to April 2023, patients who met the inclusion criteria but did not meet the exclusion criteria constituted the development cohort for retrospective analysis, and NOFI was developed. Patients recruited consecutively between May 2023 and July 2023 constituted the validation cohort for the prospective analysis for independent external validation of NOFI. Initially, a backward stepwise method was employed to conduct a multivariate logistic regression analysis in the development cohort, aiming to identify the optimal-fit model. Subsequently, a nomogram was derived from this model. The validation of the nomogram was carried out in an independent external validation cohort, where discrimination and calibration were evaluated. Additionally, a decision curve analysis was conducted to assess the net benefit of utilizing the nomogram for decision-making.

RESULTS

A total of 628 and 143 patients, 49.0 % and 51.7 % of patients occurred FI, were included in the development and validation cohort, respectively. We developed a NOFI in severely ill patients and the primary diagnosis, Acute gastrointestinal injury (AGI) grade, and APACHE II score were independent predictors of FI, with the OR of the primary diagnosis of circulatory disease being 2.281 (95 % CI, 1.364-3.816; P = 0.002); The OR of respiratory diseases was 0.424 (95 % CI, 0.259-0.594; P = 0.001); The OR of AGI grade was 4.920 (95 % CI, 3.773-6.416; P < 0.001), OR of APACHE II score was 1.100 (95 % CI, 1.059-1.143; P < 0.001). Independent external validation of the prediction model was performed. This model has good discrimination and calibration. The decision curve analysis of the nomogram provided better net benefit than the alternate options (full early enteral nutrition or delayed enteral nutrition).

CONCLUSIONS

The prediction of enteral feeding intolerance can be conveniently facilitated by the NOFI that integrates primary diagnosis, AGI grade, and APACHE II score in critically ill patients.

Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis

Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.

Decision tree model for early use of semi-elemental formula versus standard polymeric formula in critically ill Malaysian patients: A cost-effectiveness study

BACKGROUND

Prevention of enteral feeding interruption (EFI) improves clinical outcomes of critically ill intensive care unit (ICU) patients. This leads to shorter ICU stays and thereby lowers healthcare costs. This study compared the cost of early use of semi-elemental formula (SEF) in ICU vs standard polymeric formula (SPF) under the Ministry of Health (MOH) system in Malaysia.

METHODS

A decision tree model was developed based on literature and expert inputs. An epidemiological projection model was then added to the decision tree to calculate the target population size. The budget impact of adapting the different enteral nutrition (EN) formulas was calculated by multiplying the population size with the costs of the formula and ICU length of stay (LOS). A one-way sensitivity analysis (OWSA) was conducted to examine the effect each input parameter has on the calculated output.

RESULTS

Replacing SPF with SEF would lower ICU cost by MYR 1059 (USD 216) per patient. The additional cost of increased LOS due to EFI was MYR 5460 (USD 1114) per patient. If the MOH replaces SPF with SEF for ICU patients with high EFI risk (estimated 7981 patients in 2022), an annual net cost reduction of MYR 8.4 million (USD 1.7 million) could potentially be realized in the MOH system. The cost-reduction finding of replacing SPF with SEF remained unchanged despite the input uncertainties assessed via OWSA.

CONCLUSION

Early use of SEF in ICU patients with high EFI risk could potentially lower the cost of ICU care for the MOH system in Malaysia.

Application and effectiveness of an improved endoscopically guided nasojejunal tube placement technique in critically ill patients: a retrospective cohort study

Background

The endoscopic nasojejunal (NJ) placement plays a pivotal role in the nutritional support of critically ill patients. However, the conventional endoscopy-guided tube insertion method presents issues of excessive procedural duration. We have enhanced the traditional endoscopy-guided catheter placement method, enabling a faster and more convenient catheter insertion.

Methods

We improved the traditional endoscopically guided technique by incorporating an extra silk thread knot at the 25 cm mark on the jejunal segment of the NJ tube to assist endoscopists in accurate tube placement. We conducted the improved NJ tube placement on critically ill patients in need of enteral nutrition (EN). Laboratory data were retrospectively collected before and after the 7-day period of NJ tube placement and EN treatment to evaluate the effectiveness and safety of the improved method.

Results

A total of 88 critically ill patients, with an average age of 59.6±15.5 years, and a male ratio of 86.4%, who underwent the improved NJ tube placement method were enrolled into analysis finally, achieving a 100% success rate of NJ tube insertion. The average time for tube insertion was 5.9±2.2 min, with a mean insertion depth of 108.8±12.5 cm. The EN tolerance score was 0.79±0.98. Following 7 days of EN therapy, the patients showed significant improvement in serum albumin levels compared to baseline (36.42 vs. 33.66 g/L, P<0.001).

Conclusions

The improved endoscopically guided NJ tube placement technique is a rapid and safe procedure with excellent patient tolerance. It significantly improves the nutritional status of critically ill patients and facilitates the administration of EN, which requires further validation through randomized controlled trials.

Pediatric Shock Review

Shock occurs when there is energy failure due to inadequate oxygen/glucose delivery to meet metabolic demands. Shock is a leading cause of death and disability in children worldwide. Types of shock include hypovolemic, cardiogenic, distributive, and obstructive. This review provides an overview of the epidemiology, pathophysiology, and clinical signs and symptoms of each of these types of shock, followed by a discussion of advancements in diagnostic tests and tools and management/treatment principles for different categories of shock.

Modified Nutrition Risk in the Critically ill score and mortality in critically ill patients with traumatic brain injury

BACKGROUND

Understanding the relationship between nutrition risk at admission to the intensive care unit (ICU) and the prognosis of patients with traumatic brain injury (TBI) may aid early recognition of high-risk patients.

METHODS

We extracted data from the Medical Information Mart for Intensive Care III and the electronic ICU Collaborative Research Databases. Using modified Nutrition Risk in the Critically ill score (mNUTRIC) within the first 24 h of ICU admission, 5153 patients were divided into three groups: low (≤1, n = 1765), moderate (2-4, n = 2574), and high (≥5, n = 814). The primary outcome was 28-day in-hospital mortality, and the secondary outcomes were 7-day in-hospital mortality, length of ICU stay, and duration of mechanical ventilation.

RESULTS

During the median follow-up time of 6.69 days, 647 deaths occurred in total. After adjustment for potential confounding factors, setting the low mNUTRIC group as a reference, the risk of 28-day mortality was increased in the high and moderate mNUTRIC groups (hazard ratio [HR]high vs low [95% CI]: 4.21 [2.70-6.58] and 2.84 [1.95-4.14], respectively). Similarly, high and moderate mNUTRIC scores are linked to a higher risk of 7-day mortality (PTrend  < 0.001) and a longer duration of mechanical ventilation (PTrend  < 0.001). The effect of mNUTRIC on mortality varied by serum glucose level (PInteraction  = 0.01). Lastly, those whose mNUTRIC scores deteriorated within the first 3 days have a 1.46 times greater risk of dying compared with patients with improved mNUTRIC scores.

CONCLUSIONS

Nutrition risk screening by mNUTRIC score at the time of admission to the ICU may improve mortality prediction.

Early enteral nutrition is associated with improved outcomes in critically ill mechanically ventilated medical and surgical patients

BACKGROUND AND AIMS

Data suggest that guidelines for enteral nutrition (EN) initiation are not closely followed in clinical practice. In addition, critically ill mechanically ventilated (MV) patients have varying metabolic needs, which often increase and persist over time, requiring personalized nutrition intervention. While both over- and under-nutrition can impact patient outcomes, recent data suggest that targeted early EN delivery may reduce mortality and improve clinical outcomes. This study examined if early EN improves clinical outcomes and decreases costs in critically ill patients on MV.

METHODS

Data from a nationwide administrative-financial database between 2018 and 2020 was utilized to identify eligible adult critical care patients. Patients who received EN within 3 days after intubation (early EN) were compared to patients who started EN after 3 days of intubation (late EN). Outcomes of interest included hospital mortality, discharge disposition, hospital and intensive care unit (ICU) length of stay (LOS), MV days, and total cost. After inverse-probability-of-treatment weighting, outcomes were modeled using a nominal logistic regression model for hospital mortality and discharge disposition, a linear regression model for cost, and Cox proportional-hazards model for MV days, hospital and ICU LOS.

RESULTS

A total of 27,887 adult patients with early MV were identified, of which 16,772 (60.1%) received early EN. Regression analyses showed that the early EN group had lower hospital mortality (OR = 0.88, 95% CI, 0.82 to 0.94), were more likely to be discharged home (OR = 1.47, 95% CI 1.38 to 1.56), had fewer MV days (HR = 1.23, 95% CI, 1.11 to 1.37), shorter hospital LOS (HR = 1.43, 95% CI, 1.33 to 1.54) and ICU LOS (HR = 1.36, 95% CI, 1.27 to 1.46), and lower cost (-$21,226; 95% CI, -$23,605 to -$18,848) compared to the late EN group.

CONCLUSIONS

Early EN within 3 days of MV initiation in real-world practice demonstrated improved clinical and economic outcomes. These data suggest that early EN is associated with decreased hospital mortality, increased discharge to home, and decreased hospital and ICU LOS, time on MV, and cost compared to delayed initiation of EN; highlighting the importance of early EN to optimize utcomes ando support the recovery of critically ill patients on MV.

Implementation of the ESPEN guideline on clinical nutrition in the intensive care unit (ICU): It is time to move forward!: A position paper from the 'nutrition in the ICU' ESPEN special interest group

Nutritional assessment and provision of nutritional therapy are a core part of intensive care unit (ICU) patient treatment. The ESPEN guideline on clinical nutrition in the ICU was published in 2019. However, uncertainty and difficulties remain regarding its full implementation in daily practice. This position paper is intended to help ICU healthcare professionals facilitate the implementation of ESPEN nutrition guidelines to ensure the best care for their patients. We have aimed to emphasize the guideline recommendations that need to be implemented in the ICU, are advised, or are optional, and to give practical directives to improve the guideline recommendations in daily practice. These statements were written by the members of the ICU nutrition ESPEN special interest group (SIG), based on a survey aimed at identifying current practices relating to key issues in ICU nutrition. The ultimate goal is to improve the ICU patients quality of care.

Controlled enteral nutrition in critical care patients - A randomized clinical trial of a novel management system

PURPOSE

Nutritional therapy is essential to ICU care. Successful early enteral feeding is hindered by lack of protocols, gastrointestinal intolerance and feeding interruptions, leading to impaired nutritional intake. smART+ was developed as a nutrition management feeding platform controlling tube positioning, reflux, gastric pressure, and malnutrition. This study evaluated the potential of this new ICU care platform to deliver targeted nutrition and improve ICU outcomes.

METHODS

Critically ill patients ≥18 years-old, mechanically ventilated and enterally fed, were randomized to receive ESPEN-guideline-based nutrition or smART+ -guided nutrition for 2-14 days. Primary endpoint was average deviation from daily targeted nutrition determined via calculation of energy targets per calorimetry. Secondary endpoints included gastric residual volumes, length of stay (LOS) and length of ventilation (LOV).

RESULTS

smART+ achieved a mean deviation from daily targeted nutrition of 10.5% (n = 48) versus 34.3% for control (n = 50), p < 0.0001. LOS and LOV were decreased in the smART+ group versus control (mean LOS: 10.4 days versus 13.7; reduction 3.3 days, adjusted HR 1.71, 95% CI:1.13,2.60, p = 0.012; mean LOV: 9.5 days versus 12.8 days reduction of 3.3 days, adjusted HR 1.64, 95% CI:1.08-2.51, p = 0.021). Feeding goals were met (within ±10%) on 75.7% of days for smART+ versus 23.3% for control (p < 0.001). No treatment-related adverse events occurred in either group. The study was stopped due to success in a planned interim analysis of the first 100 patients.

CONCLUSION

The smART+ Platform improved adherence to feeding goals and reduced LOS and LOV versus standard of care in critically ill patients.

TRIAL REGISTRATION

NCT04098224; registered September 23, 2019.

Gastrin attenuates sepsis-induced myocardial dysfunction by down-regulation of TLR4 expression in macrophages

Myocardial dysfunction is the most serious complication of sepsis. Sepsis-induced myocardial dysfunction (SMD) is often associated with gastrointestinal dysfunction, but its pathophysiological significance remains unclear. The present study found that patients with SMD had higher plasma gastrin concentrations than those without SMD. In mice, knockdown of the gastrin receptor, cholecystokinin B receptor (Cckbr), aggravated lipopolysaccharide (LPS)-induced cardiac dysfunction and increased inflammation in the heart, whereas the intravenous administration of gastrin ameliorated SMD and cardiac injury. Macrophage infiltration plays a significant role in SMD because depletion of macrophages by the intravenous injection of clodronate liposomes, 48 h prior to LPS administration, alleviated LPS-induced cardiac injury in Cckbr-deficient mice. The intravenous injection of bone marrow macrophages (BMMs) overexpressing Cckbr reduced LPS-induced myocardial dysfunction. Furthermore, gastrin treatment inhibited toll-like receptor 4 (TLR4) expression through the peroxisome proliferator-activated receptor α (PPAR-α) signaling pathway in BMMs. Thus, our findings provide insights into the mechanism of the protective role of gastrin/CCKBR in SMD, which could be used to develop new treatment modalities for SMD.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Effect of early achievement of energy target by different nutritional support strategies on nosocomial infections in patients undergoing major abdominal surgery: a secondary analysis of two randomized clinical trials

BACKGROUND

The effect of early achievement of energy targets (EAETs) using different nutritional support strategies in patients undergoing major abdominal surgery is unclear. This study determined the impact of EAETs on the incidence of nosocomial infections in patients undergoing major abdominal surgery.

METHODS

This was a secondary analysis of two open-label randomized clinical trials. Patients from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and at nutritional risk (Nutritional risk screening 2002≥3) were divided into two groups based on whether they met the 70% energy targets, the EAET (521 EAET and non-achievement of energy target (114 NAET) groups. The primary outcome was the incidence of nosocomial infections between postoperative day 3 and discharge, and the secondary outcomes were actual energy and protein intake, postoperative noninfectious complications, intensive care unit admission, mechanical ventilation, and hospital stay.

RESULTS

Overall, 635 patients [mean (SD) age, 59.5 (11.3) years] were included. The EAET group received more mean energy between days 3 and 7 than the NAET group (22.7±5.0 vs. 15.1±4.8 kcal/kg/d; P <0.001). The EAET group had significantly fewer nosocomial infections than the NAET group [46/521(8.8%) vs. 21/114(18.4%); risk difference, 9.6%; 95% CI, 2.1-17.1%; P =0.004]. A significant difference was found in the mean (SD) number of noninfectious complications between the EAET and NAET groups [121/521(23.2%) vs. 38/114(33.3%); risk difference, 10.1%; 95% CI, 0.7-19.5%; P =0.024]. The nutritional status of the EAET group was significantly improved at discharge compared with the NAET group ( P <0.001), and other indicators were comparable between groups.

CONCLUSION

EAETs was associated with fewer nosocomial infections and improved clinical outcomes, regardless of the nutritional support strategy (early enteral nutrition alone or combined with early supplemental parenteral nutrition).

Association of early-onset constipation and diarrhoea with patient outcomes in critically ill ventilated patients: A retrospective observational cohort study

BACKGROUND

Constipation and diarrhoea are closely related, but few studies have examined them simultaneously.

OBJECTIVES

The purpose of this study was to describe patient defecation status after intensive care unit (ICU) admission and determine the association between early-onset constipation and diarrhoea following ICU admission with outcomes for critically ill ventilated patients.

METHODS

Patients ventilated for ≥48 h in an ICU were retrospectively investigated, and their defecation status was assessed during the first week after admission. Early-onset constipation and diarrhoea were defined as onset during the first week of ICU admission. The patients were divided into three groups-normal defecation, constipation, and diarrhoea-and multiple comparisons were performed using the Kruskal-Wallis test and the Mann-Whitney U test with Bonferroni adjustment. Additionally, multivariable analysis was performed for mortality and length of stay using the linear and logistic regression models.

RESULTS

Of the 85 critically ill ventilated patients, 47 (55%) experienced early-onset constipation and 12 (14%) experienced early-onset diarrhoea. Patients with normal defecation and diarrhoea increased from the 4th and 5th day of ICU admission. Early-onset diarrhoea was significantly associated with the length of ICU stay (B = 7.534, 95% confidence interval: 0.116-14.951).

CONCLUSIONS

Early-onset constipation and diarrhoea were common in critically ill ventilated patients, and early-onset diarrhoea was associated with the length of ICU stay.