A retrospective study about the influence of early nutritional support on mortality and nosocomial infection in the critical care setting

Feasibility of Achieving Nutritional Adequacy in Critically Ill Children with Critical Neurological Illnesses (CNIs)?-A Quaternary Hospital Experience

The literature on the nutritional needs and outcomes of critically ill children is scarce, especially on those with critical neurological illnesses (CNIs). Current evidence shows a lower mortality in patients who achieve two-thirds of their nutritional needs during the first week of pediatric intensive care unit (PICU) admission. We hypothesized that achieving 60% of the recommended dietary intake during the first week of a PICU stay is not feasible in patients with CNI. We designed an observational retrospective cohort study where we included all index admissions to the PICU in our institution of children (1 month to 18 years) with CNI from January 2018 to June 2021. We collected patient demographics, anthropometric measures, and caloric and protein intake (enteral and parenteral) information during the first week of PICU admission. Goal adequacy for calories and protein was defined as [(intake/recommended) × 100] ≥ 60%. A total of 1112 patients were included in the nutrition assessment, 12% of whom were underweight (weight for age z score < -2). Of this group, 180 met the criteria for nutrition support evaluation. On the third day of admission, 50% of the patients < 2 years achieved caloric and protein goal adequacy, compared to 25% of patients > 2 years, with p-values of 0.0003 and 0.0004, respectively. Among the underweight patients, 60% achieved both caloric and protein goal adequacy by day 3 vs. 30% of non-underweight patients with p-values of 0.0006 and 0.002, respectively. The results show that achieving 60% of the recommended dietary intake by days 5 and 7 of admission was feasible in more than half of the patients in this cohort. Additionally, children who were evaluated by a clinical dietician during the first 48 h of PICU admission reached higher nutrition adequacy.

Use of feeding tubes in 112 cats in an internal medicine referral service (2015-2020)

OBJECTIVES

The aims of this study were to describe diseases, complications and outcomes associated with the use of feeding tubes in a population of sick cats with appetite disturbance managed at an internal medicine referral service.

METHODS

Clinicopathological data from cats receiving nasoenteral (NE) or oesophagostomy (O) tubes were studied. Cats were categorised according to their underlying disease and divided into subgroups (NE or O tube). The following factors associated with survival were analysed: disease category, type of tube and return to appetite.

RESULTS

Included in the study were 112 cats, representing 118 cases. Of the 118 cases, 98 (83%) and 20 (17%) received NE or O tubes, respectively. The most common underlying conditions were digestive (13.5%), hepatobiliary (11%) and upper urinary tract (11%) disorders. Hepatobiliary (50%) and upper respiratory tract (30%) conditions were predominant in the O tube group. Digestive (15%) and upper urinary tract (12%) diseases were more common in the NE tube group. Complications following tube placement occurred in 22/118 cases (18.6%). The global survival rate was 73% and did not differ between NE (71.4%) and O tube (80%) groups (P = 1.00) or disease categories (P = 0.61). Return of appetite before feeding tube removal occurred in 56 cases (47%), within a median of 3 days (range 1-30) and was not associated with mirtazapine administration (P = 1.00). Appetite returned earlier for cats with NE tubes (3 days, range 1-17) than for those with O tubes (33 days, range 5-60; P <0.05). Voluntary food intake was positively associated with survival (odds ratio 15.17). After discharge and feeding tube retrieval, return of appetite was observed in 67% of cases.

CONCLUSIONS AND RELEVANCE

Feeding tubes were predominantly placed for the management of appetite disturbance in cats with digestive, hepatobiliary and upper urinary tract diseases. While complications were frequent, they were mostly mild, easily managed and did not preclude feeding tube use. Return to appetite occurred in a large proportion of cats during or after assisted enteral feeding and was associated with survival.

Appetite-stimulating effect of gabapentin vs mirtazapine in healthy cats post-ovariectomy

OBJECTIVES

The aim of the study was to evaluate the appetite-stimulating effect of gabapentin by comparing it with mirtazapine in healthy cats in the first 8 h after ovariectomy surgery.

METHODS

This double-masked, placebo-controlled, prospective clinical trial included 60 healthy cats presented to the hospital for ovariectomy: 20 received gabapentin, 21 received mirtazapine and 19 received a placebo immediately before and 6 h after surgery. Food was offered at 2, 4, 6 and 8 h post-ovariectomy. After each meal, food intake was measured. Data were analysed using repeated-measure ANOVA and a linear mixed-model analysis. Post-hoc Tukey's honest significant difference test was performed for multiple comparisons.

RESULTS

Food intake increased in both treatment groups vs placebo. No statistically significant difference was found between cats treated with gabapentin or mirtazapine.

CONCLUSIONS AND RELEVANCE

Cats receiving gabapentin ate more than cats in the placebo group. Thirty percent of cats in the gabapentin group covered their resting energy requirements, while none of the cats in the placebo group did. Gabapentin and mirtazapine produced similar effects on food intake.

Effects of probiotics combined with early enteral nutrition on endothelin-1 and C-reactive protein levels and prognosis in patients with severe traumatic brain injury

OBJECTIVE

To investigate the effects of probiotics combined with early enteral nutrition on levels of endothelin-1 (ET-1), C-reactive protein (CRP), and inflammatory factors, and on the prognosis of patients with severe traumatic brain injury (TBI).

METHODS

We enrolled 76 adults with severe TBI. The patients were divided randomly into two equal groups administered enteral nutrition with and without probiotics, respectively. Demographic and clinical data including age, sex, Glasgow Coma Scale score, Sequential Organ Failure Score, Acute Physiology, Chronic Health Score, hospitalization, mortality, and infections were recorded.

RESULTS

Serum levels of inflammatory factors gradually decreased with increasing treatment time in both groups. However, ET-1 at 15 days, and interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-α, and CRP at 7 and 15 days decreased significantly more in the combined treatment group. Hospitalization duration and pulmonary infection rates were also significantly reduced in the combined compared with the enteral nutrition alone group. GCS scores at 15 days were significantly lower in the combined compared with the enteral nutrition group.

CONCLUSION

Probiotics combined with early enteral nutrition could reduce serum levels of ET-1, CRP, and IL-6, IL-10, and TNF-α, and could thus improve the recovery of patients with severe TBI.

Plasma free carnitine in severe trauma: Influence of the association with traumatic brain injury

BACKGROUND

Metabolic response to severe trauma requires early nutritional resuscitation. Carnitine is essential for lipolysis, the energy source during this hypercatabolic phase. However l-carnitine is not present in nutritional replacement solutions. Furthermore, free carnitine depletion, defined as carnitine plasma level under 36μmol/L, was not adequately reported in adult patients with severe trauma. The aim of this study was to assess plasma free carnitine levels and factors of variation in severe trauma.

METHOD

Our observational study concerned 38 trauma patients including 18 with traumatic brain injury (TBI). On the third day after trauma, plasma free carnitine concentration was determined (by enzymatic method) while patients received artificial nutrition.

RESULTS

Low plasmatic free carnitine concentration was evidenced in 95% of the patients with a median value of 18μmol/L (11-47). Univariate analysis showed that mean arterial pressure, serum urea, CKD-EPI and patients with TBI were significantly associated with plasma free carnitine concentration less than 18μmol/L. Lower plasma free carnitine concentration was observed in the group of patients with TBI with 17.72μmol/L (11-36) versus 21.5μmol/L (11-47) for others patients (p=0.031). Logistic regression analysis showed that severe trauma with TBI and CKD-EPI above 94mL/min/1.73m2 appeared to be independent predictor of lower free carnitine plasmatic concentration (Goodness of fit=0.87 and AUC=0.89).

CONCLUSION

Our observations support hypotheses that plasma free carnitine concentration is lowered in severe injured patients especially for TBI patients and patients with estimated GFR above 94mL/min/1.73m².

Effect of early enteral nutrition on patients with digestive tract surgery: A meta-analysis of randomized controlled trials

Postoperative early enteral nutrition (EEN) is useful for the effective recovery of patients that have undergone surgery. However, the feasibility and efficacy of EEN in patients with digestive tract surgery remain inconclusive. In the present meta-analysis, the PubMed, EMBASE, Web of Science, The Cochrane Library, China National Knowledge Infrastructure and VIP databases were searched to identify controlled trials of patients with and without EEN following digestive tract surgery between October, 1966 and December, 2014. Methodological quality assessment was carried out for each of the included studies. For estimation of the analysis indexes, relative risk (RR) was used as the effect size of the the categorical variable, while the weighted mean difference (MD) was used as the effect size of the continuous variable. The meta-analysis was conducted using RevMan 5.2 software. Eleven randomized controlled trials involving 1,095 patients were included in the meta-analysis. The results revealed that, EEN in patients with digestive tract surgery was more effective in decreasing the incidence of infectious [RR=0.50, 95% confidence interval (CI): 0.38, 0.67; P<0.01] and non-infectious complications (RR=0.72, 95% CI: 0.43, 1.22; P<0.05) and shortening the length of first bowel action (MD=−4.10, 95% CI: −5.38, −2.82; P<0.05). It also had a significant influence on increasing the serum albumin (MD=2.87, 95% CI: 1.03, 4.71; P<0.05) and serum prealbumin (MD=0.04, 95% CI: 0.02, 0.05; P<0.05) levels. In conclusion, the results of the study have shown that EEN in patients with digestive tract surgery improved the nutritional status, reduced the risk of postoperative complications, shortened the length of hospital stay and promoted the functional recovery of the digestive system.

Route of nutrition and risk of blood stream infections in critically ill patients; a comparative study

BACKGROUND AND AIMS

The association of nutritional support practices with intensive care unit (ICU) - acquired infections is a current field of interest. The objective of this study was to determine whether different routes of delivery of nutritional support are associated with a different risk of bloodstream infection (BSI) in critically ill patients.

METHODS

An observational study in a multidisciplinary ICU. Adult ICU patients, with ICU stay ≥96 h who were fed artificially were included. Patients were grouped into three categories of nutrition support routes: those on enteral nutrition alone (EN group), on parenteral nutrition alone (PN group) or on both EN and PN (EN+PN group). Illness severity, co-morbidities and routine laboratory values were recorded on ICU admission. Route of feeding, caloric, protein and immunonutrient intake was recorded daily for each patient. Nosocomial BSIs were identified by infection control surveillance methods. The incidence of BSI among the three groups was compared with Kaplan-Meier plots and Cox proportional-hazards models.

RESULTS

A total of 249 patients were included in the analysis. There were no significant differences between groups in illness severity scores and in the time to nutritional support initiation (median time 48 [24-48] hours). The median daily caloric intake was significantly lower for the EN group than for patients of PN and EN+PN group (415 [157-687] kcal vs. 1077 [297-2087] kcal and 1292 [890-1819] kcal respectively, p < 0.001). BSI occurred in 69 (27.7%) patients. Bivariate Cox analysis revealed that APACHE II score and admission category were significantly associated to BSI development [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01-1.09 and HR 0.45; 95% CI 0.18-1.15, respectively]. Presence of co-morbidities, SOFA score, hospital length of stay (LOS) before ICU admission, late initial feeding, serum albumin at admission, average daily maximum concentration of serum glucose, caloric, protein and immunonutrient intake did not affect the hazard of BSI development. After adjustment for the confounding variables, in a multivariate analysis, patients of the EN + PN group had lower incidence of BSI than the other two groups (HR 0.30; 95% CI 0.17-0.53), irrespective of the number of days of PN intake and the percentage of calories received from PN. There was no difference in the hazard for BSI development between the EN and PN group. Patients with EN + PN had a significantly longer ICU-LOS whereas mortality was not different among the three groups.

CONCLUSIONS

In this retrospective analysis of 249 consecutively enrolled ICU patients, we found that in critically ill patients EN + PN feeding strategy was associated with a significantly reduced hazard of BSI development, compared to EN or PN route of nutritional support.

Influence of supplemental parenteral nutrition approach on nosocomial infection in pediatric intensive care unit of Emergency Department: a retrospective study

BACKGROUND & AIMS

Nutritional support for patients in the intensive-care unit (ICU) is a part of standard care which promotes medical quality and decreases nosocomial infection. Supplemental parenteral nutrition (SPN) approach (enteral nutrition (EN) combined with parenteral nutrition (PN) when EN alone is insufficient) has become one major concern in nutrition research field. This research aims to explore the following relationships: (i) the relationship between SPN and nosocomial infection, (ii) the relationship between early and late SPN initiation and the development of nosocomial infection.

METHODS

A retrospective study was conducted in patients who met the inclusion criteria from February 2012 to February 2015 in Pediatric ICU (PICU). Patients were classified into two groups according to nutrition delivery approach-SPN group and EN alone group. Then SPN group were further divided into two subgroups by initiation timing, which were defined as early-initiation SPN and late-initiation SPN group respectively. Age, gender, serum albumin at admission, severity of disease, length of stay in PICU, nutrition delivery approach, amounts of delivered caloric intake and occurence of nosocomial infection were recorded. Univariate analysis and binary logistic regression analysis were performed to identify the risk factors and assess the independent effect of SPN approach on nosocomial infection in PICU of Emergency Department.

RESULTS

204 patients were included in our study. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate (34.0 vs.10.9%, p < 0.001). The late-initiation subgroup of SPN approach was found to be an independent predictor of nosocomial infection in the logistic regression analysis model (OR = 3.40; 95% CI, 1.13 ~ 10.19; p = 0.029). Serum albumin at admission (OR = 0.91; 95% CI, 0.84 ~ 0.97; p = 0.008), mechanical ventilation (OR = 3.85; 95% CI, 1.43 ~ 10.39; p = 0.008), severity of disease (OR = 3.79; 95% CI, 1.03 ~ 13.99; p = 0.045) and PICU length of stay (OR = 1.23; 95% CI, 1.11 ~ 1.35; p < 0.001) were also identified as significant risk factors for nosocomial infection.

CONCLUSIONS

Our study shows late-initiation SPN approach increases the incidence of nosocomial infection compared with early-initiation approach in critically ill children in PICU of Emergency Department. Compared with EN alone group, patients delivered by SPN approach had a higher nosocomial infection rate.

Predictors of Clostridium difficile infection severity in patients hospitalised in medical intensive care

AIM: To describe and analyse factors associated with Clostridium difficile infection (CDI) severity in hospitalised medical intensive care unit patients.

METHODS: We performed a retrospective cohort study of 40 patients with CDI in a medical intensive care unit (MICU) at a French university hospital. We include patients hospitalised between January 1, 2007 and December 31, 2011. Data on demographics characteristics, past medical history, CDI description was collected. Exposure to risk factors associated with CDI within 8 wk before CDI was recorded, including previous hospitalisation, nursing home residency, antibiotics, antisecretory drugs, and surgical procedures.

RESULTS: All included cases had their first episode of CDI. The mean incidence rate was 12.94 cases/1000 admitted patients, and 14.93, 8.52, 13.24, 19.70, and 8.31 respectively per 1000 admitted patients annually from 2007 to 2011. Median age was 62.9 [interquartile range (IQR) 55.4-72.40] years, and 13 (32.5%) were women. Median length of MICU stay was 14.0 d (IQR 5.0-22.8). In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. The duration of diarrhoea was 13.0 (8.0-19.5) d. In addition to diarrhoea, the clinical symptoms of CDI were fever (> 38 °C) in 23 patients, abdominal pain in 15 patients, and ileus in 1 patient. Prior to CDI, 38 patients (95.0%) were exposed to antibiotics, and 12 (30%) received at least 4 antibiotics. Fluoroquinolones, 3^rd generation cephalosporins, coamoxiclav and tazocillin were prescribed most frequently (65%, 55%, 40% and 37.5%, respectively). The majority of cases were hospital-acquired (n = 36, 90%), with 5 cases (13.9%) being MICU-acquired. Fifteen patients had severe CDI. The crude mortality rate within 30 d after diagnosis was 40% (n = 16), with 9 deaths (9 over 16; 56.3%) related to CDI. Of our 40 patients, 15 (37.5%) had severe CDI. Multivariate logistic regression showed that male gender [odds ratio (OR): 8.45; 95%CI: 1.06-67.16, P = 0.044], rising serum C-reactive protein levels (OR = 1.11; 95%CI: 1.02-1.21, P = 0.021), and previous exposure to fluoroquinolones (OR = 9.29; 95%CI: 1.16-74.284, P = 0.036) were independently associated with severe CDI.

CONCLUSION: We report predictors of severe CDI not dependent on time of assessment. Such factors could help in the development of a quantitative score in ICU’s patients.

Enteral nutrition in critical care

There is a consensus that nutritional support, which must be provided to patients in intensive care, influences their clinical outcome. Malnutrition is associated in critically ill patients with impaired immune function and impaired ventilator drive, leading to prolonged ventilator dependence and increased infectious morbidity and mortality. Enteral nutrition is an active therapy that attenuates the metabolic response of the organism to stress and favorably modulates the immune system. It is less expensive than parenteral nutrition and is preferred in most cases because of less severe complications and better patient outcomes, including infections, and hospital cost and length of stay. The aim of this work was to perform a review of the use of enteral nutrition in critically ill patients.