Monitoring nutrition in the ICU

Toward Precision in Nutrition Therapy

Precision in critical care nutrition is paramount, as it focuses nutrition interventions on those patients most likely to benefit, or those who might potentially be harmed. Critical care nutrition must therefore be tailored to individual metabolic needs as determined by factors that control the capacity for tissue homeostasis and anabolic responses. This ideally involves the accurate and timely assessment of macronutrient and micronutrient requirements, a careful evaluation of metabolic response mechanisms and the identification of circumstances that might interfere with the productive utilization of dietary substrates. Specific surrogate markers of metabolic response, such as blood glucose levels, urea levels, or nitrogen balance, might be used to evaluate the metabolic readiness for nutrition and to establish the timing, nature, and clinical effectiveness of nutrition interventions. Despite the pressing need to further develop more targeted approaches in critically ill patients, indices of immediate metabolic responses that correlate with favorable clinical outcomes are lacking. In addition, the development of precision approaches might address timely adjustments in protein, energy, or micronutrient supplementation based on evolving clinical conditions. Here, we review why precision tools are needed in critical care nutrition, our progress thus far, as well as promising approaches and technologies by which multidisciplinary healthcare teams can improve quality of care and clinical outcomes by individualizing nutrition interventions.

Association between Poor Outcomes and Risk of Refeeding Syndrome among Patients Urgently Admitted to the High Dependency Unit: A Single-Center Cohort Study in Japan

Background/Objectives: Refeeding syndrome (RFS) is recognized as a potentially fatal metabolic disturbance, particularly concerning for non-critically ill patients who do not receive frequent electrolyte assessments. Assessing the risk of developing RFS and implementing preventive strategies is essential in these cases. We investigated the proportion of risk and its association with prognosis in a high-dependency unit (HDU). Method: This observational study was conducted in a tertiary care hospital's HDU in Japan. We consecutively enrolled all patients who had been admitted urgently to the HDU and hospitalized for three days or more. We evaluated the National Institute for Health and Clinical Excellence (NICE) RFS risk factors at admission and classified patients into four groups based on the modified NICE criteria. The primary outcome was 30-day in-hospital mortality. The secondary outcome was a composite of 30-day in-hospital mortality and transfer to the intensive care unit, or discharge to locations other than home. Using logistic regression, we assessed the association between the four risk groups and outcomes, using the no-risk group as a reference. Results: A total of 955 patients were analyzed, of which 33.1%, 26.7%, 37.8%, and 2.4% were classified into the no-risk, low-risk, high-risk, and very high-risk groups, respectively. The 30-day in-hospital mortality was 4.4%, 5.5%, 5.0%, and 21.7%, respectively (Log-rank trend test: p = 0.047). In multivariable logistic regression, adjusting for sepsis, comorbidities, and age, only the very high-risk group was associated with 30-day in-hospital mortality (odds ratio: 5.54, 95% confidence interval: 1.73-17.79) A similar association was observed for the secondary outcomes. Conclusions: For patients admitted urgently to the HDU, there may be an opportunity to improve outcomes for very high-risk patients through preventive strategies.

Validation of the nutritrauma concept for the detection of potential harmful effects of medical nutritional treatment in critically ill patients in real life

Introduction

Introduction: medical nutritional treatment (MNT) can be complex and may be associated with potential metabolic complications, which has been recently described as nutritrauma. Objective: the aim of our work is to describe whether the application of the nutritrauma concept in real life is feasible and useful to detect the metabolic complications associated with the prescription of MNT. Material and methods: in this descriptive, prospective study at a single center we enrolled 30 consecutive critically ill patients in a 14-bed medical-surgical intensive care unit. The nutritrauma strategy implementation was based in four "M" steps: Metabolic screening, MNT prescription, biochemical Monitoring, and nutritional Management. Results: we analyzed 28 patients (mean age, 69.7 ± 11.3 years; APACHE II, 18.1 ± 8.1; SOFA, 7.5 ± 3.7; Nutric Score, modified, 4.3 ± 2.01, and mean BMI, 27.2 ± 3.8). The main cause of admission was sepsis (46.4 %). Length of ICU stay was 20.6 ± 15.1 days; 39.3 % of subjects died during their ICU stay. Enteral nutrition (82.1 %) was more frequent than parenteral nutrition (17.9 %). During nutritional monitoring, 54 specific laboratory determinations were made. Hyperglycemia was the most frequent metabolic alteration (83.3 % of measurements). Electrolyte disturbances included hypocalcemia (50 %), hypophosphatemia (29.6 %) and hypokalemia (27.8 %). The most frequent lipid profile abnormalities were hypocholesterolemia (64.8 %) and hypertriglyceridemia (27.8 %). Furthermore, nutritional prescription was modified for 53.6 % of patients: increased protein dosage (25 %), increased calorie dosage (21.4 %) and change to organ-specific diet (17.8 %). Conclusions: in conclusion, the application of the nutritrauma approach facilitates detection of metabolic complications and an evaluation of the appropriate prescription of MNT.

Nutrition considerations for patients with persistent critical illness: A narrative review

Critically ill patients experience high rates of malnutrition and significant muscle loss during their intensive care unit (ICU) admission, impacting recovery. Nutrition is likely to play an important role in mitigating the development and progression of malnutrition and muscle loss observed in ICU, yet definitive clinical trials of nutrition interventions in ICU have failed to show benefit. As improvements in the quality of medical care mean that sicker patients are able to survive the initial insult, combined with an aging and increasingly comorbid population, it is anticipated that ICU length of stay will continue to increase. This review aims to discuss nutrition considerations unique to critically ill patients who have persistent critical illness, defined as an ICU stay of >10 days. A discussion of nutrition concepts relevant to patients with persistent critical illness will include energy and protein metabolism, prescription, and delivery; monitoring of nutrition at the bedside; and the role of the healthcare team in optimizing nutrition support.

Nutrition in the intensive care unit: from the acute phase to beyond

Recent randomized controlled trials (RCTs) have shown no benefit but  dose-dependent harm by early full nutritional support in critically ill patients. Lack of benefit may be explained by anabolic resistance, suppression of cellular repair processes, and aggravation of hyperglycemia and insulin needs. Also early high amino acid doses did not provide benefit, but instead associated with harm in patients with organ dysfunctions. However, most studies focused on nutritional interventions initiated during the first days after intensive care unit admission. Although the intervention window of some RCTs extended into the post-acute phase of critical illness, no large RCTs studied nutritional interventions initiated beyond the first week. Hence, clear evidence-based guidance on when and how to initiate and advance nutrition is lacking. Prolonged underfeeding will come at a price as there is no validated metabolic monitor that indicates readiness for medical nutrition therapy, and an adequate response to nutrition, which likely varies between patients. Also micronutrient status cannot be assessed reliably, as inflammation can cause redistribution, so that plasma micronutrient concentrations are not necessarily reflective of total body stores. Moreover, high doses of individual micronutrients have not proven beneficial. Accordingly, current evidence provides clear guidance on which nutritional strategies to avoid, but the ideal nutritional regimen for individual patients remains unclear. In this narrative review, we summarize the findings of recent studies, discuss possible mechanisms explaining the results, point out pitfalls in interpretation of RCTs and their effect on clinical practice, and formulate suggestions for future research.

External validation and updating of the infusion rate individualization of soybean oil-based intravenous lipid emulsion: A descriptive cohort study

BACKGROUND

Safe and efficient provision of intravenous lipid emulsion (ILE) requires a strategy to individualize infusion rates. Estimating the maximum acceptable infusion rate (MaxInfRate) of soybean oil-based ILE (SO-ILE) in individuals by using a triglyceride (TG) kinetic model was reported to be feasible. In this study, we aimed to externally validate and, if needed, update the MaxInfRate estimation.

METHODS

The maximum TG concentration (TGmax) in patients receiving SO-ILE at MaxInfRate was evaluated to determine if it met the definition of being <400 mg/dl for 90th percentile of patients. The TG kinetic model was evaluated through prediction performance checks and was subsequently updated using the data set of both the previous model development and present validation studies.

RESULTS

Out of 83 patients, 74 had TGmax <400 mg/dl, corresponding to a probability of 89.2% (95% CI, 81.9%-95.2%), and the 90th percentile of TGmax was 400 mg/dl (95% CI, 328-490 mg/dl), closely aligned with the theoretical values. However, the individual TGmax values were biased by the infusion rate because the covariate effects were overestimated in the TG kinetic model, requiring a minor revision. The updated MaxInfRate with the combined data set showed unbiased and more accurate predictions.

CONCLUSION

The MaxInfRate was validated in external inpatients and updated with all available data. MaxInfRate estimation for individuals could be an option for the safe and efficient provision of SO-ILE.

Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients

BACKGROUND & AIMS

Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients.

METHODS

This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance.

RESULTS

We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047).

CONCLUSION

Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.

Higher serum prealbumin levels are associated with higher graft take and wound healing in adult burn patients: A prospective observational trial

INTRODUCTION

Nutritional support is essential in burn care. There are few studies investigating the effect of nutrition on burn healing. The purpose of this study was to determine the relationship between perioperative serum prealbumin levels and the probability of autologous skin graft take in burned patients.

MATERIALS AND METHODS

A prospective observational study was carried out with burned adults recruited consecutively from April 2019 until September 2021. Serum prealbumin was determined perioperatively. The percentage of graft take was evaluated over the first 5 postoperative dressing changes. Time until full epithelialization (absence of wounds) was also registered.

RESULTS

A total of 60 patients were recruited, mostly middle-aged people with moderate flame burns. Serum prealbumin levels and graft take had a weak-moderate, nonlinear, statistically significant correlation. They were also an independent predictor of full epithelialization on the fifth dressing change, together with burn depth. Higher perioperative serum prealbumin levels were significantly associated with a reduction in time until full epithelialization.

CONCLUSIONS

Perioperative serum prealbumin levels are significantly correlated with the probability of split-thickness skin autograft take in burned patients and with a reduced time to achieve complete epithelialization. They were an independent predictor of full graft take.

Nutritional and Metabolic Status Control and Nutritional Support in Patients with Pancreatic Sepsis (Review)

Acute pancreatitis (AP) is associated with pancreonecrosis in 30% of patients, who may fall at 80% high risk of death when infected pancreatic necrosis progresses to sepsis. Given the catabolic nature of the disease and the significant influence of nutritional status on its course and outcome, these patients require an adequate nutritional support (NS) based on an adequate assessment and control of nutritional and metabolic status.

The aim of the study: to identify trends in developing new tools for assessment of nutritional and metabolic status, and provision of NS in patients with pancreatic sepsis (PS).

Materials and methods

. Keyword search in the PubMed, Scopus and E-library databases for the period from 2018 to 2023 yielded 95 publications, of which 16 meta-analyses and 6 systematic reviews met the requirements.

Results. all existing to date scales for assessment of nutritional deficiency in patients with PS have low prognostic value. Of them, mNUTRIC scale seems to be the most appropriate assessment tool. Recommended by EPSEN guidelines tools to assess the risk of nutritional deficiency it is not suitable for ICU patients. Indirect calorimetry should be preferred vs routine calculation formulas in assessing patient’s energy needs in case of PS. It was also found that «standard» anthropometric values, such as BMI, are not always informative and prognostically significant in patients with severe AP in the ICU. Analgesia, infusion therapy, as well as detection and correction of intraperitoneal hypertension are not only integral components of intensive care for PS but are indispensable for supplying adequate NS in PS patients. It was found that early enteral nutrition is the preferred method of NS, although questions concerning choice of tube insertion site, as well as all parameters of tube feeding remain unanswered. The optimal composition of enteral nutrition for patients with PS has not been established, which is indirectly confirmed by the variety of enteral mixtures available on the market. The refeeding syndrome that occurs at initiation of NS was characterized as a life-threatening condition.

Conclusion. NS, based on adequate assessment of disorders and control of the nutritional and metabolic status is an integral component of intensive care in PS patients. It can reduce the probability and number of potential complications, time of stay in the ICU, cost of treatment, and improve patient’s prognosis.

Effect of a multidisciplinary nutrition management model in patients with critical illness: A randomized trial

BACKGROUND

Managing nutrition in critically ill patients involves many medical fields. However, the nutrition management of critically ill patients has not been comprehensive enough to achieve multidisciplinary team cooperation in China and many other countries. Furthermore, there is no standardized management model or process.

AIM

To explore the multidisciplinary cooperative nutrition management model for critically ill patients in the ICUs in China, verify its clinical effect and provide a clinical practice reference for the nutrition management of critically ill patients.

STUDY DESIGN

A multidisciplinary cooperative nutrition management team, including ICU doctors, ICU nurses, clinical nutritionists, clinical pharmacists and radiologists, was established for critically ill patients. According to a literature review and domestic guidelines, the standardized process of nutritional management for critically ill patients was constructed through the Delphi expert consultation method. One hundred thirty-two patients in the ICU were randomly divided into an experimental group and a control group. A routine nutrition management mode, which was the nutrition management plan mainly formulated by the ICU doctor in charge only and the ICU nurses responsible for the implementation and monitoring of nutrition support, was implemented in the control group. And a multidisciplinary nutrition management mode, which was the nutrition management implemented by the multidisciplinary teams with the standardized nutrition management process for critically ill patients, was adopted in the experimental group. The early nutritional support rate, nutritional indexes (serum albumin, preprotein, haemoglobin and hs-CPR), mechanical ventilation time, ICU hospitalization days and hospitalization expenses of the two groups were compared.

RESULTS

The early nutritional support rates of the experimental group and the control group were 89.39% and 69.7%, respectively (χ2  = .002, p = .031). Serum albumin (35.4 vs. 33.1 g/L), preprotein (153.2 vs. 125.9 mg/L) and haemoglobin (97.5 vs. 90.6 g/L) in the experimental group were significantly higher than in the control group (p = .000, .016, .033). The days of hospitalization in the ICU of the experimental group were shorter than in the control group (5.1 vs. 7.1, p = .039). High-sensitivity C-reactive protein, the days of mechanical ventilation and ICU hospitalization expenses of the experimental group were lower than in the control group; however, the difference was not statistically significant (p = .713, .068, .489).

CONCLUSIONS

Because of the severity and complexity of patients' diseases, it is necessary to implement multidisciplinary nutrition management for critically ill patients. Research shows that the multidisciplinary nutrition management standardized process for critically ill patients that was constructed in this study can effectively improve nutritional indexes such as serum albumin, preprotein and haemoglobin, shorten the length of stay in the ICU and promote the rehabilitation of patients, and this process be widely used in the clinic.

RELEVANCE TO CLINICAL PRACTICE

Structured multidisciplinary nutrition management operational processes can guide clinical practice. They could be widely used in the clinical nutrition management of critically ill patients in critical care units or other departments.

Factors Associated with Nutritional Risk Assessment in Critically Ill Patients Using the Malnutrition Universal Screening Tool (MUST)

Background: Malnutrition is an underdiagnosed condition that negatively affects the clinical outcomes of patients, being associated with an increased risk of adverse events, increased hospital stay, and higher mortality. Therefore, nutritional assessment is a required and necessary process in patient care. The objective of this study was to identify the factors associated with nutritional risk by applying the Malnutrition Universal Screening Tool (MUST) scale in a population of critically ill patients. Methods: This was an observational, analytical, and retrospective study. Sociodemographic, clinical, hematological, and biochemical variables and their relationship with nutritional risk and mortality were analyzed. Results: Of 630 patients, the leading cause of admission was pathologies of the circulatory and respiratory system (50%); 28.4% were at high nutritional risk; and mortality was 11.6% and associated with nutritional risk, hemoglobin, and plasma urea nitrogen. Conclusions: The presence of gastrointestinal symptoms and the type of nutritional support received during hospitalization could increase the likelihood of presenting a medium/high nutritional risk, while polycythemia reduced this probability. An associative model was found to determine nutritional risk with an adequate specificity and diagnostic validity index.

Evaluating Nutritional Risk Factors for Delirium in Intensive-Care-Unit Patients: Present Insights and Prospects for Future Research

Malnutrition, hypercatabolism, and metabolic changes are well-established risk factors for delirium in critically ill patients. Although the exact mechanisms are not fully understood, there is mounting evidence suggesting that malnutrition can cause a variety of changes that contribute to delirium, such as electrolyte imbalances, immune dysfunction, and alterations in drug metabolism. Therefore, a comprehensive metabolic and malnutrition assessment, along with appropriate nutritional support, may help to prevent or ameliorate malnutrition, reduce hypercatabolism, and improve overall physiological function, ultimately lowering the risk of delirium. For this aim, bioelectrical impedance analysis can represent a valuable strategy. Further research into the underlying mechanisms and nutritional risk factors for delirium is crucial to developing more effective prevention strategies. Understanding these processes will allow clinicians to personalize treatment plans for individual patients, leading to improved outcomes and quality of life in the intensive-care-unit survivors.

Changes in body composition of burn patients during the phases of response to trauma

OBJECTIVE

To assess the changes in body composition of burn patients through electrical bioimpedance in the phases of response to trauma.

METHODS

a longitudinal observational study, carried out from October 2019 to March 2020. Sociodemographic, clinical, epidemiological, anthropometric and body composition data were collected. Statistical analysis was performed with SPSS, considering a significance of 5%. The comparison between variables was performed using the paired Student's t test.

RESULTS

the sample consisted of 58 adult burn patients, with a mean age of 38.2±12.5 years. The mean body surface area (BSA) with burns was 10.8±7.3%. Nutritional assessment demonstrated a depletion of body weight, Body Mass Index, fat-free mass and muscle mass in the phases of response to trauma (p<0.005).

CONCLUSION

metabolic alterations in the different phases of the metabolic response to trauma led to a depletion of the nutritional status of burn patients of both sexes during hospitalization.

[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.

Micronutrient intake to protect against osteoporosis during and after critical illness

PURPOSE OF REVIEW

Improved survival from critical illness has enhanced the focus on ways to augment functional outcomes following discharge from the Intensive Care Unit. An area that is gaining increased attention is the effect of critical illness on bone health and fragility fractures following the episode. This review discusses the micronutrients that may play a role in bone metabolism and the potential benefits of their supplementation to prevent osteoporosis. These include calcium, phosphorous, magnesium, vitamin D, vitamin C, vitamin K, and certain trace elements.

FINDINGS

Although there is sound physiological basis for the involvement of these micronutrients in bone health and fracture prevention, there are few clinically relevant publications in this area with calcium and vitamin D being the best studied to date.

SUMMARY

In the absence of high-quality evidence in critically ill populations, attention to measurement and supplementation of these micronutrients as per current guidelines outlining micronutrient requirements in enteral and parenteral nutrition might mitigate bone loss and its sequelae in the recovery phase from critical illness.

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.

Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study

BACKGROUND & AIMS

After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay.

METHODS

This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality.

RESULTS

572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%.

CONCLUSION

BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

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.

Personalized nutrition therapy in critical care: 10 expert recommendations

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

Nutritional and metabolic characteristics of critically ill patients admitted for severe toxidermia

INTRODUCTION

Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU.

METHOD

Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital.

INCLUSION CRITERIA

Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia.

VARIABLES

severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median [IQR].

RESULTS

Altogether 35 patients were included (27 SJS/TEN and 8 "other"), aged 58 [48; 69] years. Skin involvement was 45% [30; 60] of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 [6.5; 26] days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 [89; 218] mg/L). The first 2 weeks' energy and protein intakes were below recommendations (p < 0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 [23.9; 35.5] kcal/kg) resulting in negative energy balances (mean -245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding.

CONCLUSION

Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube.

CLINICALTRIALS

gov Identifier: NCT05320653.

Burns: Classification, Pathophysiology, and Treatment: A Review

Burns and their treatment are a significant medical problem. The loss of the physical barrier function of the skin opens the door to microbial invasion and can lead to infection. The repair process of the damage caused by the burn is impaired due to the enhanced loss of fluids and minerals through the burn wound, the onset of hypermetabolism with the concomitant disruption of nutrient supply, and derangements in the endocrine system. In addition, the initiated inflammatory and free radical processes drive the progression of oxidative stress, the inhibition of which largely depends on an adequate supply of antioxidants and minerals. Clinical experience and research provide more and more data to make the treatment of patients with thermal injury increasingly effective. The publication discusses disorders occurring in patients after thermal injury and the methods used at various stages of treatment.

Toward nutrition improving outcome of critically ill patients: How to interpret recent feeding RCTs?

Although numerous observational studies associated underfeeding with poor outcome, recent randomized controlled trials (RCTs) have shown that early full nutritional support does not benefit critically ill patients and may induce dose-dependent harm. Some researchers have suggested that the absence of benefit in RCTs may be attributed to overrepresentation of patients deemed at low nutritional risk, or to a too low amino acid versus non-protein energy dose in the nutritional formula. However, these hypotheses have not been confirmed by strong evidence. RCTs have not revealed any subgroup benefiting from early full nutritional support, nor benefit from increased amino acid doses or from indirect calorimetry-based energy dosing targeted at 100% of energy expenditure. Mechanistic studies attributed the absence of benefit of early feeding to anabolic resistance and futile catabolism of extra provided amino acids, and to feeding-induced suppression of recovery-enhancing pathways such as autophagy and ketogenesis, which opened perspectives for fasting-mimicking diets and ketone supplementation. Yet, the presence or absence of an anabolic response to feeding cannot be predicted or monitored and likely differs over time and among patients. In the absence of such monitor, the value of indirect calorimetry seems obscure, especially in the acute phase of illness. Until now, large feeding RCTs have focused on interventions that were initiated in the first week of critical illness. There are no large RCTs that investigated the impact of different feeding strategies initiated after the acute phase and continued after discharge from the intensive care unit in patients recovering from critical illness.

Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study

BACKGROUND

Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort.

METHODS

The 'French-Speaking ICU Nutritional Survey' (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses.

RESULTS

During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23-2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00-1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01-1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98-1.11).

CONCLUSIONS

In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk. Trial registration ClinicalTrials.gov Identifier: NCT02599948. Retrospectively registered on November 5th 2015.

The effects of adjunctive treatment with L-carnitine on monitoring laboratory variables in ICU patients: a double-blinded randomized controlled clinical trial

BACKGROUND

Critically ill patients must be monitored constantly in intensive care units (ICUs). Among many laboratory variables, nutritional status indicators are a key role in the prognosis of diseases. We investigated the effects of L-carnitine adjunctive therapy on monitoring variables in critical illness.

METHOD

A prospective, double-blind, randomized controlled trial was implemented in a medical ICU. Participants were 54 patients, aged > 18 years, with multiple conditions, randomly assigned to receive 3 g L-carnitine per day or placebo, along with enteral feeding, for 1 week. Primary outcomes included monitoring variables related to nutritional status.

RESULT

Of 54 patients randomly assigned, 51 completed the trial. Serum albumin (Alb) (P-value: 0.001), total protein (P-value: 0.003), and calcium (Ca) (0.044) significantly increased in the intervention vs. control group. Alanine transaminase (ALT) (0.022), lactate (<0.001), creatinine (Cr) (0.005), and international normalized ratio (INR) (0.049) decreased meaningfully in the intervention vs. control group.

CONCLUSION

L-Carnitine supplementation in critically ill patients can improve several parameters including INR, Cr, ALT, lactate, Ca, Alb, and total protein.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT 20151108024938N2. This trial was approved by the Research Ethics Committee of Mashhad University of Medical Sciences (registration code: IR.MUMS.fm.REC.1396.671) (available at https://en.irct.ir/trial/30748 , May 2018).

Incidence and impact of malnutrition in patients with Fontan physiology

BACKGROUND

Single-ventricle patients require a series of surgeries, with the final stage being the Fontan. This form of circulation results in several long-term complications, but the impact and consequences of nutrition status remain unclear. We sought to evaluate the incidence of malnutrition in Fontan patients and the impact on outcomes.

METHODS

This study was a retrospective cohort study of children who underwent Fontan surgery between 1997 and 2018. Clinical, demographic, and nutrition data were collected, including weight, height, body mass index (BMI), and their respective z scores (z score for weight-for-age [WAZ], z score for height-for-age [HAZ], and z score for BMI-for-age [BMIZ]) pre-Fontan, at discharge, 6 months, and 1, 5, and 10 years post-Fontan. Malnutrition status was categorized using the American Society for Parenteral and Enteral Nutrition guidelines and the Michigan MTool. Fontan failure was defined as listing for heart transplant or death.

RESULTS

Of the 69 patients, moderate-severe malnutrition occurred at any time point in 11% (n = 8) by WAZ, 16% (n = 11) by HAZ, and 6% (n = 4) by BMIZ. Moderate-severe malnutrition persisted in 6.5%-12.9% at 10 years post-Fontan. Compared with the pre-Fontan period, there was no change in these parameters over time. There was no statistically significant difference in Fontan failure between degrees of pre-Fontan malnutrition.

CONCLUSION

There is a 6%-16% incidence of moderate-severe malnutrition in Fontan patients. Malnutrition is a condition that remains present in follow-up. There was no association with anthropometric parameters and transplant-free survival. A prospective multi-institutional study is needed to understand the impact of malnutrition on long-term outcomes.

Modified low ratio ketogenic therapy in the treatment of adults with super-refractory status epilepticus

BACKGROUND

Induction of ketosis by manipulation of nutrition intake has been proposed as an adjunctive treatment for super-refractory status epilepticus (SRSE). However, the classical 4:1 ketogenic ratio may not meet the nutrition needs, specifically protein for critically ill adults. The aim of this study was to analyze the outcomes of adults with SRSE who received a lower ketogenic ratio of 2:1 grams of fat to non-fat grams, including 20%-30% of energy from medium chain triglycerides.

METHODS

We reviewed patients aged ≥18 years with SRSE treated with ketogenic therapy between July 2015 and December 2020 at two quaternary teaching hospitals in Melbourne, Australia. Data collected from medical records included patient demographics, nutrition prescription, clinical outcomes, and ketogenic therapy-related complications. The primary outcome of the study was to assess tolerability of ketogenic therapy.

RESULTS

Twelve patients (female = 7) were treated with ketogenic therapy for SRSE. Patients received between 4 and 8 antiseizure medications and 1-5 anesthetic agents prior to commencement of ketogenic therapy. Blood beta-hydroxybutyrate concentrations were variable (median = 0.5 mmol/L, range: 0.0-6.1 mmol/L). SRSE resolved in 10 cases (83%) after a median of 9 days (range: 2-21 days) following commencement of ketogenic therapy. Ketogenic therapy-associated complications were reported in five patients, leading to cessation in two patients.

CONCLUSION

Despite the challenge in maintaining ketosis during critical illness, low ratio 2:1 ketogenic therapy incorporating medium chain triglycerides is tolerable for adults with SRSE. Further studies are required to determine the optimal timing, nutrition prescription and duration of ketogenic therapy for SRSE treatment.

The Extent of Burn Injury Significantly Affects Serum Micro- and Macroelement Concentrations in Patients on the First Day of Hospitalisation

Burns exceeding 30% of total body surface area (TBSA) result in considerable hypovolemia coupled with the formation and release of inflammatory mediators, leading to subsequent systemic effects known as burn shock. Because of plasma exudation and the associated losses of large quantities of minerals, severe burns can lead to nutritional deficiencies and consequently disrupt homeostasis and metabolism of the entire body. The study group comprised 62 patients, who were divided into 3 groups according to the severity of burns. Serum samples were tested for concentrations of Ca, Mg, Mn, P, K, Zn, Cu, Fe, Se, Na, Cr, Ni, and Al. The mineral concentrations in serum of patients with burn injuries differ significantly from reference values, but this is not affected by the extent of the body burn. There are statistically significant decreases in serum concentrations of elements important for antioxidant protection (Zn, Cu, Se), and significant increases in the concentrations of toxic elements (Al and Ni), which may aggravate the effects associated with the state of burn shock. The Spearman rank correlation analysis did not reveal any statistically significant relationships between the serum concentrations of Mn, Ni, Al, K, Na, P, Mg, Zn, Se, Cr and the affected body surface area and severity of the burn—the values were at the lower end of the reference range. The obtained results indicate that proper nutrition, including elements replenishment, is extremely important in the recovery process of burn patients and time to nutrition is an important factor affecting patient survival after severe burn.

[Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]

At the time of admission to an intensive or intermediate care unit, assessment of the patients' nutritional status may have both prognostic and therapeutic relevance with regard to the planning of individualized medical nutrition therapy (MNT). MNT has definitely no priority in the initial treatment of a critically ill patient, but is often also neglected during the course of the disease. Especially with prolonged length of stay, there is an increasing risk of malnutrition with considerable prognostic macro- and/or micronutrient deficit. So far, there are no structured, evidence-based recommendations for assessing nutritional status in intensive or intermediate care patients. This position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) presents consensus-based recommendations for the assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units. These recommendations supplement the current S2k guideline "Clinical Nutrition in Intensive Care Medicine" of the German Society for Nutritional Medicine (DGEM) and the DIVI.

Effect of Early Low-Calorie Enteral Nutrition Support in Critically Ill Patients: A Systematic Review and Meta-analysis

Objective

The purpose of this research was to rigorously assess the impact of early low-fever enteral feeding supplementation in critically sick patients.

Methods

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database were searched for randomized controlled trials related to enteral nutrition support of critically ill patients (retrieval time was limited to June 30, 2021); data were extracted after screening the literature, and the quality of meta-analysis was evaluated.

Results

When compared to adequate caloric enteral nutrition support, early low caloric enteral nutrition support reduces the incidence of intolerance to nutrition support (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13) and the insulin dose during enteral nutrition support (MD = -17.21, 95 percent CI: -19.91 to -14.51, P = 0.00001). However, it had no effect on intensive care unit (ICU) treatment duration (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), in-hospital mortality (MD = 0.60, 95 percent CI: -0.18 to 1.39, P = 0.13), or infection incidence (OR = 1.00, 95 percent CI: 0.85, 1.19, P = 0.98).

Conclusion

When compared to sufficient caloric enteral nutrition support, early low-calorie enteral nutrition support lowers the risk of severe illness. The rate of intolerance to nutritional assistance and the decrease in insulin dosage supplied had no effect on the length of ICU therapy, patient death, or infection incidence.

Extracorporeal Life Support Organization Guidelines for the Provision and Assessment of Nutritional Support in the Neonatal and Pediatric ECMO Patient

DISCLAIMER

This guideline is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but Extracorporeal Life Support Organization (ELSO) is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

ESPEN micronutrient guideline

BACKGROUND

Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome.

OBJECTIVE

This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement".

METHODS

The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations.

RESULTS

There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed.

CONCLUSION

This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.

Nutritional support protocol for patients with COVID-19

BACKGROUND & AIMS

COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19.

METHODS

A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients.

RESULTS

The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge.

CONCLUSION

Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

Correlations between First 72 h Hypophosphatemia, Energy Deficit, Length of Ventilation, and Mortality-A Retrospective Cohort Study

INTRODUCTION

Hypophosphatemia may prolong ventilation and induce weaning failure. Some studies have associated hypophosphatemia with increased mortality. Starting or restarting nutrition in a critically ill patient may be associated with refeeding syndrome and hypophosphatemia. The correlation between nutrition, mechanical ventilation, and hypophosphatemia has not yet been fully elucidated.

METHODS

A retrospective cohort study of 825 admissions during two consecutive years was conducted. Using the electronic medical chart, demographic and clinical data were obtained. Hypophosphatemia was defined as a phosphate level below 2.5 mg/dL (0.81 mmol/L) in the first 72 h of ICU admission. Comparisons between baseline characteristics and outcomes and multivariate analysis were performed.

RESULTS

A total of 324 (39.27%) patients had hypophosphatemia during the first 72 h of ICU admission. Patients with hypophosphatemia tended to be younger, with lower APACHE-II, SOFA24, and ΔSOFA scores. They had a longer length of stay and length of ventilation, more prevalent prolonged ventilation, and decreased mortality. Their energy deficit was lower. There was no effect of hypophosphatemia severity on these results. In multivariate analysis, hypophosphatemia was not found to be statistically significant either with respect to mortality or survivor's length of ventilation, but lower average daily energy deficit and SOFA24 were found to be statistically significant with respect to survivor's length of ventilation.

CONCLUSION

Hypophosphatemia had no effect on mortality or length of ventilation. Lower average daily energy deficit is associated with a longer survivor's length of ventilation.

Proceedings of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition Monothematic Conference, 2020: "Acute Liver Failure in Children": Treatment and Directions for Future Research

OBJECTIVES

The Hepatology Committee of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) aims to educate pediatric gastroenterologists, members of ESPGHAN and professionals from other specialties promoting an exchange of clinical expertise in the field of pediatric hepatology.

METHODS

The 2020 single topic ESPGHAN monothematic 3-day conference on pediatric liver disease, was organized in Athens, Greece and was entitled " Acute Liver Failure" (ALF). ALF is a devastating disease with high mortality and in a considerable fraction of patients, the cause remains unresolved. As knowledge in diagnosis and treatment of ALF in infants and children has increased in the past decades, the objective was to update physicians in the field with developments in medical therapy and indications for liver transplantation (LT) and to identify areas for future research in clinical and neurocognitive outcomes in ALF.

RESULTS

We recently reported the epidemiology, diagnosis, and initial intensive care management issues in separate manuscript. Herewith we report on the medical treatment, clinical lessons arising from pediatric studies, nutritional and renal replacement therapy (RRT), indications and contraindications for LT, neurocognitive outcomes, new techniques used as bridging to LT, and areas for future research. Oral presentations by experts in various fields are summarized highlighting key learning points.

CONCLUSIONS

The current report summarizes the current insights in medical treatment of pediatric ALF and the directions for future research.

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines

BACKGROUND

Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.

METHODS

A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.

RESULTS

Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.

CONCLUSIONS

Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

When is parenteral nutrition indicated?

The indications and contraindications of parenteral nutrition (PN) are discussed in view of recent clinical findings. For decades, PN has been restricted to patients unable to tolerate enteral nutrition (EN) intake owing to the perceived risk of severe side-effects. The evolution of the PN substrate composition and delivery of nutrition via all-in-one bags has dramatically improved the application prospects of PN. Recent studies show similar complication rates of nutrition therapy administered through enteral and intravenous routes. Therefore, indications of PN have, based on evidence, extended beyond complete gastrointestinal (GI) failure to include conditions such as insufficient EN generating persistent negative energy balance and insufficient protein intakes, malabsorption, or specific needs that are impossible to cover with EN feeds.

A Systematic Review and Meta-Analysis of the effectiveness of continuous versus intermittent enteral nutrition in critically ill adults

BACKGROUND

Continuous Enteral Nutrition (CEN) remains standard practice in Intensive Care Units (ICUs) worldwide. Intermittent Enteral Nutrition (IEN) may be a suitable alternative method. This meta-analysis aims to investigate the safety, tolerance, and effectiveness of IEN compared to CEN in critically ill adults in the ICU.

METHODS

Medline, CINAHL, Scopus, Embase and Google Scholar were searched for studies published up until 30^th April 2020, along with manual searches in bibliographies. Eligible studies were trials that compared CEN versus IEN feeding in the ICU, and reported on at least one of the relevant outcomes - nutritional intake, gastric residual volume (GRV), aspiration pneumonia, vomiting, diarrhea, abdominal distension, glycemic variability. Secondary outcomes were ICU length of stay (LOS) and mortality. The Cochrane risk-of-bias tool for randomized trials was used to assess methodological quality.

RESULTS

Ten studies with 664 participants were included in the meta-analysis. The majority of studies had an overall 'High' risk of bias. Incidence of vomiting was significantly higher in CEN as compared to IEN groups (Risk Ratio 2.76; 95% CI, 1.23 - 6.23). There were no significant differences between CEN and IEN groups for nutritional intake, GRV, the incidence of aspiration pneumonia, diarrhea, abdominal distension, ICU LOS, and mortality. Definition and reporting of outcome measures were not standardized across studies, hence this heterogeneity limits generalisability of results.

CONCLUSION

Overall, the safety, tolerance, and effectiveness of CEN and IEN were found to be comparable. Future studies should explore monitoring larger sample sizes to determine best feeding practices in ICU. This article is protected by copyright. All rights reserved.

A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice

The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

Comparison of Biochemical and Pathological Parameters and Parenteral Nutrition of ICU Patients Under Supervision of Dietitians and Surgeons

Background: Nutrient imbalance can frequently occur in patients with indications for parenteral nutrition (PN) after gastrointestinal surgery. This study aimed to compare the recommendations of a surgeon to those of a dietitian in the field of parenteral nutrition.

Methods: This study was performed on 256 patients undergoing gastrointestinal surgery who received PN, which included 120 patients who received PN based on recommendations of the surgeons and 136 patients who were referred to receive PN under the supervision of a dietitian in Razi Hospital in Rasht, Iran. Data on PN and clinical outcomes of the patients were collected.

Results: Patients under the supervision of dietitians received higher vitamin B complex and lipids and lower vitamin A and vitamin E than the surgeon-supervised patients (all P < 0.001). In the group receiving PN under the supervision of a surgeon, the level of blood glucose (207 vs. 182, P < 0.01), sodium (138 vs. 136, P = 0.01), potassium (3.97 vs. 3.53, P < 0.01), and white blood cell count (9.83 vs. 9.28, P < 0.01) increased significantly at the end of the PN compared to baseline. In the group receiving PN under the supervision of a dietician, the level of serum Cr (1.23 vs. 1.32, P = 0.04), Mg (2.07 vs. 1.84, P < 0.01), and pH (7.45 vs. 7.5, P = 0.03) significantly improved after receiving parenteral nutrition compared to baseline.

Conclusion: The amounts of nutrients recommended for PN by the surgeon and dietitian were different. Implementation of dietitian recommendations in critically ill patients under PN can improve patients' clinical parameters.

Protein prescription and delivery practices in critically ill adults: A survey of Australian and New Zealand intensive care dietitians

BACKGROUND

Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance.

OBJECTIVES

The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions.

METHODS

A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions.

RESULTS

Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present.

CONCLUSIONS

Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.

Early Prediction for Persistent Inflammation-Immunosuppression Catabolism Syndrome in Surgical Sepsis Patients

Objective

To find the predictors for persistent inflammation-immunosuppression catabolism syndrome in ICU surgical septic patients.

Design

Single center observation study.

Participants

Inclusion: 1) patients ≥18, 2) admitted to the ICU after major surgery or transferred to the ICU within 48 hours after the diagnosis of sepsis following the definition of sepsis-3.0. Exclusion: 1) pregnant or lactating patients, 2) patients with severe immune deficiency, 3) patients that expired within 14 days after the diagnosis of sepsis.

Results

A total of 169 participants were included. After propensity score matching, PICS patients were found to have higher intensive care unit (ICU) mortality (32.4% vs 12.4%, p=0.046), 90-day mortality (32.4% vs 9.1%, p=0.006), and ICU-acquired infection rate (44.1% vs 12.7%, p<0.001), and longer ICU stays (29 vs 11 days, p<0.001) comparing to non-PICS patients. In multivariate logistic regression, it demonstrated that the SOFA score, Charlson co-morbidity index (CCI), albumin level on the ICU day 1, and lymphocyte count on the ICU day 3 were statistically significant. Sensitivity analysis was conducted with the receiver operating characteristic curve for a combination of the four parameters and the area under the curve was 0.838 (95% confidence interval 0.774–0.901).

Conclusion

The chronic disease condition and decreased immunity in the early course of sepsis were crucial for PICS. The combination of CCI, SOFA score, albumin level on ICU Day 1 and lymphocyte count on ICU Day 3 can be early predictor for PICS.

CE: Monitoring Adult Patients for Intolerance to Gastric Tube Feedings

ABSTRACT

Gastric tube feeding is a common and valuable intervention for patients in a variety of care settings. While tube feeding can save the lives of patients for whom oral feeding isn't possible, intolerance to tube feeding is a potential complication. This article discusses risk factors for feeding intolerance; the assessment of signs and symptoms of feeding intolerance; the various means of assessing gastric emptying, including the practice of monitoring gastric residual volume (GRV); the controversy surrounding GRV monitoring in assessing feeding tolerance; and the special considerations for monitoring feeding tolerance in acutely and critically ill adults with coronavirus disease 2019. The author, a nurse researcher with extensive experience in the area of enteral feeding, briefly summarizes recommendations and guidelines for enteral feeding published by national and international health care organizations between 2015 and 2020, and offers her perspective on best nursing practices for monitoring food tolerance in adults.

Role and knowledge of critical care nurses in the assessment and management of hypophosphataemia and refeeding syndrome. A descriptive exploratory study

OBJECTIVE

To assess the perceived and actual role of critical care nurses in nutritional care, and their knowledge regarding the identification and management of hypophosphataemia and refeeding syndrome.

DESIGN AND METHODS

Data were collected in one intensive care unit in Israel, from a self-administered questionnaire completed by 42 critical care nurses. The questionnaire was designed to assess their perceived and actual roles in the administration of nutritional care, and knowledge regarding electrolyte monitoring, hypophosphataemia and refeeding syndrome, including risk factors, consequences, and treatment.

RESULTS

The majority participants that dieticians are solely responsible for nutrition care and follow-up. Most agreed that the measurement of phosphate levels was not important and that patients should receive full nutrition upon admission, while important risk factors for the development of refeeding syndrome were not recognised or considered. This informed their actual practice. A correlation was found between nurses' knowledge and their actual practice so that the greater the nurses' knowledge, the more they adhered to current nutrition guidelines (p < 0.05).

CONCLUSIONS

This study revealed critical care nurses' lack of clarity of their role and lack of knowledge regarding nutrition care. We suggest that this complex task is best managed by a multidisciplinary team, including nurses and dieticians, with clear role definitions.

Bad Prognosis in Critical Ill Patients with COVID-19 during Short-Term ICU Stay regarding Vitamin D Levels

BACKGROUND AND AIMS

Vitamin D inadequacy may be involved in the mechanisms of SARS-CoV-2 infection and in potential risk factors for disease propagation or control of coronavirus disease 2019 (COVID-19). This study assessed a short-term evolution of vitamin D status and its influence upon different clinical parameters in critically ill patients with COVID-19.

METHODS

A prospective analytical study in which 37 critically ill volunteers between 41 and 71 years of age with COVID-19 were evaluated at baseline and three days of intensive care unit (ICU) stay. 25-OH-D₃ and 25-OH-D₂ were analyzed by liquid chromatography-tandem mass spectrometry and total 25-OH-D levels were calculated as the sum of both.

RESULTS

All patients presented low 25-OH-D levels at baseline, decreasing total 25-OH-D (p = 0.011) mainly through 25-OH-D₂ (p = 0.006) levels during ICU stay. 25-OH-D₂ levels decreased a mean of 41.6% ± 89.6% versus 7.0% ± 23.4% for the 25-OH-D₃ form during the ICU stay. Patients who did not need invasive mechanical ventilation presented higher levels of 25-OH-D₂ at baseline and follow-up. Lower 25-OH-D and 25-OH-D₃ levels were associated with higher D-dimer at baseline (p = 0.003; p = 0.001) and at follow up (p = 0.029), higher procalcitonin levels (p = 0.002; p = 0.018) at follow up, and lower percentage lymphocyte counts (p = 0.044; p = 0.040) during ICU stay.

CONCLUSIONS

Deficient vitamin D status in critical patients was established at the admission and further worsened after three days of stay. Lower vitamin D levels were related to key altered clinical and biochemical parameters on patients with SARS-CoV-2 infection. Given the different response of the 25-OH-D₃ and 25-OH-D₂ forms, it would be useful to monitor them on the evolution of the critically ill patient.

Development and validation of a laboratory risk score for the early prediction of COVID-19 severity and in-hospital mortality

BACKGROUND AND AIMS

Coronavirus Disease 2019 is characterized by a spectrum of clinical severity. This study aimed to develop a laboratory score system to identify high-risk individuals, to validate this score in a separate cohort, and to test its accuracy in the prediction of in-hospital mortality.

METHODS

In this cohort study, biological data from 330 SARS-CoV-2 infected patients were used to develop a risk score to predict progression toward severity. In a second stage, data from 240 additional COVID-19 patients were used to validate this score. Accuracy of the score was measured by the area under the receiver operating characteristic curve (AUC).

RESULTS

In the development cohort, a step-wise decrease in the average survival duration was noted with the increment of the risk score (pANOVA < 0.0001). A similar trend was confirmed when analyzing this association in the validation cohort (p < 0.0001). The AUC was 0.74 [0.66-0.82] and 0.90 [0.87-0.94], p < 0.0001, respectively for severity and mortality prediction.

CONCLUSION

This study provides a useful risk score based on biological routine parameters assessed at the time of admission, which has proven its effectiveness in predicting both severity and short-term mortality of COVID-19. Improved predictive scores may be generated by including other clinical and radiological features.

Nutritional screening based on objective indices at admission predicts in-hospital mortality in patients with COVID-19

BACKGROUND

Could nutritional status serve as prognostic factors for coronavirus disease 2019 (COVID-19)? The present study evaluated the clinical and nutritional characteristics of COVID-19 patients and explored the relationship between risk for malnutrition at admission and in-hospital mortality.

METHODS

A retrospective, observational study was conducted in two hospitals in Hubei, China. Confirmed cases of COVID-19 were typed as mild/moderate, severe, or critically ill. Clinical data and in-hospital death were collected. The risk for malnutrition was assessed using the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the Controlling Nutritional Status (CONUT) via objective parameters at admission.

RESULTS

Two hundred ninety-five patients were enrolled, including 66 severe patients and 41 critically ill patients. Twenty-five deaths were observed, making 8.47% in the whole population and 37.88% in the critically ill subgroup. Patients had significant differences in nutrition-related parameters and inflammatory biomarkers among three types of disease severity. Patients with lower GNRI and PNI, as well as higher CONUT scores, had a higher risk of in-hospital mortality. The receiver operating characteristic curves demonstrated the good prognostic implication of GNRI and CONUT score. The multivariate logistic regression showed that baseline nutritional status, assessed by GNRI, PNI, or CONUT score, was a prognostic indicator for in-hospital mortality.

CONCLUSIONS

Despite variant screening tools, poor nutritional status was associated with in-hospital death in patients infected with COVID-19. This study highlighted the importance of nutritional screening at admission and the new insight of nutritional monitoring or therapy.