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Lee K, Song IA, Lee S, Kim K, Oh TK. Multidisciplinary nutritional support team and survival outcomes in patients with sepsis: a nationwide population-based cohort study in South Korea. Eur J Clin Nutr 2024:10.1038/s41430-024-01463-3. [PMID: 38898286 DOI: 10.1038/s41430-024-01463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The South Korean government implemented a multidisciplinary nutritional support team (NST) system to focus on the proper evaluation and supply of nutritional status in hospitalized patients who are at a higher risk of malnutrition. METHODS This nationwide population-based cohort study included patients diagnosed with sepsis who were admitted to hospitals from 2016 to 2020. The NST should consist of four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). The NST group included patients with sepsis admitted to a hospital with an NST system, whereas the non-NST group included patients with sepsis admitted to a hospital without an NST system. RESULTS A total of 323,841 patients with sepsis were included in the final analysis, and 120,274 (37.1%) admitted to a hospital with an NST system were included in the NST group. In the multivariable Cox regression analysis, the NST group showed a 15% lower 90-day mortality than the non-NST group (hazard ratio [HR]:0.85, 95% confidence interval [CI]:0.83, 0.86; P < 0.001). The NST group shows 11% lower 1-year all-cause mortality than the non-NST group (HR:0.89, 95% CI:0.87, 0.90; P < 0.001). In subgroup analyses, a more evident association of the NST group with lower 90-day mortality was shown in the intensive care unit admission group and age ≥65 years old group. CONCLUSIONS Multidisciplinary NST intervention is associated with improved survival outcomes in patients with sepsis. Moreover, this association was more evident in patients with sepsis aged ≥65 years old who were admitted to the ICU.
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Affiliation(s)
- Kyunghwa Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Sunghee Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Keonhee Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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2
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Frederiks P, Peetermans M, Wilmer A. Nutritional support in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:373-379. [PMID: 38333990 DOI: 10.1093/ehjacc/zuae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/10/2024]
Abstract
Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.
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Affiliation(s)
- Pascal Frederiks
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
| | - Marijke Peetermans
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Alexander Wilmer
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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3
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Song IA, Lee K, Lee S, Kim K, Oh TK. Implementation of a multidisciplinary nutritional support team and clinical outcomes in critically ill patients with COVID-19. Clin Nutr 2024; 43:315-321. [PMID: 38142476 DOI: 10.1016/j.clnu.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 11/29/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND & AIMS The South Korean government established the multidisciplinary nutritional support teams (NST) system for enhancing the evaluation and adequate supply of nutritional support to patients at high risk of malnutrition. However, the impact of the NST on clinical outcomes in critically ill patients with coronavirus disease 2019 (COVID-19) remains unclear. We aimed to investigate whether NST implementation affects survival outcomes in patients with COVID-19 requiring intensive care unit (ICU) admission. METHODS Using data from the National Health Insurance Service and Korea Disease Control and Prevention Agency in South Korea, adult patients with COVID-19 admitted to the ICU between October 8, 2020, and December 31, 2021, were included. The NST comprised four professional personnel (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). Patients admitted to ICUs with and without the NST system were assigned to the NST and non-NST groups, respectively. RESULTS A total of 13,103 critically ill adult patients were included in the final analysis; among them, 10,103 (77.1 %) and 3,000 (22.9 %) patients were included in the NST and non-NST groups, respectively. In the NST group, 2,803 (27.7 %) critically ill patients with COVID-19 were prescribed enteral or parenteral nutrition by the NST. In a covariate-adjusted multivariable model, the NST group showed a 40 % lower in-hospital mortality rate than the non-NST group (odds ratio: 0.60, 95 % confidence interval: 0.51, 0.71; P < 0.001). In subgroup analyses, compared with the non-NST group, the NST group showed significantly lower in-hospital mortality rates at 2, 3, 4, and 5 points on the World Health Organization clinical progression scale among patients with acute respiratory distress and mechanical ventilatory support. CONCLUSIONS NST implementation was associated with improved survival outcomes in critically ill patients with COVID-19; accordingly, it may be recommended for improving adequate nutritional support and evaluation in critically ill patients.
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Affiliation(s)
- In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, South Korea
| | - Kyunghwa Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, South Korea
| | - Sunghee Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, South Korea
| | - Keonhee Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, South Korea.
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Floro GC, Schwenger KJP, Ghorbani Y, Zidar DJ, Allard JP. In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay. Nutr Clin Pract 2023; 38:1368-1378. [PMID: 37302065 DOI: 10.1002/ncp.11019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/20/2023] [Accepted: 04/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight. METHODS This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay. RESULTS One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013). CONCLUSION In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.
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Affiliation(s)
- Geraldine C Floro
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | | | - Yasaman Ghorbani
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Deanna J Zidar
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
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Tatucu-Babet OA, Diehl A, Kratzing C, Lambell K, Burrell A, Tierney A, Nyulasi I, Bailey M, Sheldrake J, Ridley EJ. Modified indirect calorimetry for patients on venoarterial extracorporeal membrane oxygenation: a pilot feasibility study. Eur J Clin Nutr 2023; 77:888-894. [PMID: 37198437 PMCID: PMC10191396 DOI: 10.1038/s41430-023-01291-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND/OBJECTIVES Traditional indirect calorimetry is unable to capture complete gas exchange in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). We aimed to determine the feasibility of using a modified indirect calorimetry protocol in patients receiving VA ECMO, report measured energy expenditure (EE) and compare EE to control critically ill patients. SUBJECTS/METHODS Mechanically ventilated adult patients receiving VA ECMO were included. EE was measured within 72 h of VA ECMO commencement (timepoint one [T1]) and on approximately day seven of Intensive Care Unit (ICU) admission (timepoint two [T2]). Traditional indirect calorimetry via the ventilator was combined with calculations of oxygen consumption and carbon dioxide production derived from pre- and post-ECMO membrane blood gas analyses. Completion of ≥60% EE measurements was deemed feasible. Measured EE was compared between T1 and T2 and to control patients not receiving VA ECMO. Data is presented as n(%) and median[interquartile range (IQR)]. RESULTS Twenty-one patients were recruited; 16(76%) male, aged 55[42-64] years. The protocol was feasible to complete at T1 (14(67%)) but not at T2 (7(33%)) due to predominantly ECMO decannulation, extubation or death. EE was 1454[1213-1860] at T1 and 1657[1570-2074] kcal/d at T2 (P = 0.043). In patients receiving VA ECMO versus controls, EE was 1577[1434-1801] versus 2092[1609-2272] kcal/d, respectively (P = 0.056). CONCLUSION Modified indirect calorimetry is feasible early in admission to ICU but is not possible in all patients receiving VA ECMO, especially later in admission. EE increases during the first week of ICU admission but may be lower than EE in control critically ill patients.
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Affiliation(s)
- Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Nutrition Department, The Alfred, Melbourne, VIC, Australia.
| | - Arne Diehl
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | | | - Kate Lambell
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Audrey Tierney
- School of Allied Health and Health Implementation Science and Technology Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, VIC, Australia
| | - Ibolya Nyulasi
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
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Lu GY, Xu H, Li JH, Chen JK, Ning YG. Safety and outcome of early enteral nutrition in patients receiving extracorporeal membrane oxygenation. Clin Nutr 2023; 42:1711-1714. [PMID: 37541102 DOI: 10.1016/j.clnu.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/30/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE To explore the benefits and risks of early enteral nutrition (EN) in patients receiving extracorporeal membrane oxygenation (ECMO). METHODS A single center retrospective review was performed including patients receiving ECMO for more than 24 h from May 2014 to July 2021. RESULTS A total of sixty-five patients were enrolled, of which thirty-six patients (55.4%) received early EN. On ECMO day 3rd, 7th and 14th, the median energy intake through EN in the early EN group was 500 kcal (IQR:300, 880), 1000 kcal (IQR: 500, 1500) and 1000 kcal (500, 1500), representing 29.7%, 66.7% and 66.7% of energy target, respectively. Thirteen (36.1%) patients had EN intolerance in the early EN group, which is significantly lower than that in the delayed EN group (82.8%, P < 0.001). The most common reasons for EN intolerance were abdominal distention (22.2%), followed by elevated gastric residual volume (8.3%) in the early EN group. Forty-three (66.1%) patients successfully weaned off ECMO, with higher rate in the early EN group than in the delayed EN group (80.6% vs 48.3%, p = 0.006). Nineteen patients (52.8%) survived in the early EN group, which is also significantly higher than that in the delayed EN group (20.7%, P = 0.008). Patients receiving early enteral nutrition significantly reduced the mortality rate and the adjusted mortality hazard ratio was 0.22 (95%CI:0.10, 0.47). CONCLUSION Early EN was safe and well-tolerated and can reduce the in-hospital mortality of patients receiving ECMO. For patients receiving ECMO, EN started with hypocaloric doses within 48 h of ECMO initiation is recommend.
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Affiliation(s)
- Gui-Yang Lu
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, No. 55 Zhenhai Road, Xiamen, 361102, Fujian, China; School of Medicine, Xiamen University, Xiamen, 361102, Fujian, China; The School of Clinical Medicine, Fujian Medical University, No. 1 Xuefu North Road, Fuzhou, 350122, Fujian, China
| | - Hao Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, No. 55 Zhenhai Road, Xiamen, 361102, Fujian, China; School of Medicine, Xiamen University, Xiamen, 361102, Fujian, China; The School of Clinical Medicine, Fujian Medical University, No. 1 Xuefu North Road, Fuzhou, 350122, Fujian, China
| | - Jian-Hua Li
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, No. 55 Zhenhai Road, Xiamen, 361102, Fujian, China; School of Medicine, Xiamen University, Xiamen, 361102, Fujian, China; The School of Clinical Medicine, Fujian Medical University, No. 1 Xuefu North Road, Fuzhou, 350122, Fujian, China
| | - Jing-Ke Chen
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, No. 55 Zhenhai Road, Xiamen, 361102, Fujian, China; School of Medicine, Xiamen University, Xiamen, 361102, Fujian, China; The School of Clinical Medicine, Fujian Medical University, No. 1 Xuefu North Road, Fuzhou, 350122, Fujian, China
| | - Yao-Gui Ning
- Department of Intensive Care Unit, The First Affiliated Hospital of Xiamen University, No. 55 Zhenhai Road, Xiamen, 361102, Fujian, China; School of Medicine, Xiamen University, Xiamen, 361102, Fujian, China; The School of Clinical Medicine, Fujian Medical University, No. 1 Xuefu North Road, Fuzhou, 350122, Fujian, China.
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Schneeweiss-Gleixner M, Scheiner B, Semmler G, Maleczek M, Laxar D, Hintersteininger M, Hermann M, Hermann A, Buchtele N, Schaden E, Staudinger T, Zauner C. Inadequate Energy Delivery Is Frequent among COVID-19 Patients Requiring ECMO Support and Associated with Increased ICU Mortality. Nutrients 2023; 15:2098. [PMID: 37432241 DOI: 10.3390/nu15092098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) patients during ECMO therapy. METHODS We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses. RESULTS Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372, p = 0.007). CONCLUSIONS Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.
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Affiliation(s)
- Mathias Schneeweiss-Gleixner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Bernhard Scheiner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Semmler
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Mathias Maleczek
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Laxar
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Marlene Hintersteininger
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Martina Hermann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexander Hermann
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Nina Buchtele
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Eva Schaden
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Staudinger
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Christian Zauner
- Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, 1090 Vienna, Austria
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Kim JY, Wie GA, Ryu KA, Kim SY. Nutrition Support in Critically Ill Cancer Patient Receiving Extracorporeal Membrane Oxygenation: A Case Report. Clin Nutr Res 2023; 12:91-98. [PMID: 37214778 PMCID: PMC10193437 DOI: 10.7762/cnr.2023.12.2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Adequate nutritional support is crucial in preventing complications and improving outcomes in critically ill patients. Extracorporeal membrane oxygenation (ECMO) is a mode of supportive care for patients with respiratory and/or cardiac failure. ECMO patients frequently exhibit a hypermetabolic state characterized by protein catabolism and insulin resistance, which can lead to malnutrition. Nutritional therapy is a vital component of intensive care, but its optimal administration for ECMO patients is unknown. This case report aims to provide insights into effective nutritional management for critically ill patients undergoing ECMO therapy. The patient was a 72-year-old male with a history of gastric and lung cancer who underwent a lobectomy complicated by bronchopleural fistula, postoperative bleeding, pneumonia, and acute respiratory distress syndrome (ARDS). The patient's nutritional status was assessed indicating a high risk of malnutrition, using the modified Nutrition Risk in the Critically Ill (mNUTRIC) Score. Nutritional support was administered based on the recommendations of European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), with energy requirements set at 25-30 kcal/kg/d and protein requirements set at 1.2-2.0 g/kg/day. The patient received parenteral nutrition until the enteral nutrition target amount was reached, with zinc supplements for wound healing. The study highlights the need for further research on proactive and effective nutritional support for ECMO patients to improve compliance and prognosis.
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Affiliation(s)
- Ji-Yeon Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Gyung-Ah Wie
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Kyoung-A Ryu
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - So-Young Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
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Herron TJ, Farach SM, Russo RM. COVID, the Gut, and Nutritional Implications. CURRENT SURGERY REPORTS 2023; 11:30-38. [PMID: 36819787 PMCID: PMC9918822 DOI: 10.1007/s40137-022-00342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 02/13/2023]
Abstract
Purpose of Review The purpose of this review is to provide an overview of the current literature, recommendations, and practice guidelines on the nutritional management of and implications associated with COVID-19 infection. Recent Findings Particular attention should be paid to the screening, prevention, and treatment of malnutrition in critically ill individuals with COVID-19 infection given the significant risk for complications and poor outcomes. Extrapolation of existing literature for the nutritional support in the critically ill patient has demonstrated early enteral nutrition is safe and well-tolerated in patients with severe COVID-19 infection. Summary Futures studies should focus on the long-term nutritional outcomes for patients who have suffered COVID-19 infection, nutritional outcomes/recommendations for special populations with COVID-19, nutritional outcomes based on the current recommendations and guidelines for nutrition therapy, and the role for micronutrient supplementation in COVID-19 infection.
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Affiliation(s)
- Thomas J. Herron
- Division of Acute Care and Trauma Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606 USA
| | - Sandra M. Farach
- Division of Acute Care and Trauma Surgery, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606 USA
| | - Rocco M. Russo
- Department of Clinical Nutrition, Tampa General Hospital, Tampa, FL USA
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10
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Effect of Enteral and Parenteral Nutrition Support on Pulmonary Function in Elderly Patients with Chronic Obstructive Pulmonary Disease Complicated by Respiratory Failure. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4743070. [PMID: 36245845 PMCID: PMC9556180 DOI: 10.1155/2022/4743070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022]
Abstract
Objective. To investigate the effect of enteral and parenteral nutrition support (EPNS) on pulmonary function in elderly patients with chronic obstructive pulmonary disease (COPD) complicated by respiratory failure (RF). Methods. A total of 127 patients who underwent treatment for elderly patients with COPD complicated by RF in our hospital from February 2020 to May 2022 were collected for a retrospective analysis. There were 41 patients with enteral nutrition support (group A), 46 with parenteral nutrition support (group B), and 40 with EPNS (group C). The levels of serum albumin (ALB), prealbumin (PA), serum hemoglobin (Hb), and serum transferrin (TRF) were measured before and after nutritional support in the three groups, and the changes in pulmonary function of patients were compared. The changes in the levels of inflammatory factors and markers of oxidative stress (OS) in serum were also detected, and the incidence of adverse reactions and length of stay (LOS) were counted. Results. ALB, PA, Hb, and TRF levels were increased in all 3 groups after nutritional support, with the highest in group C (
). Similarly, lung function was improved in all 3 groups and inflammatory factor levels and OS were suppressed, also most dramatically in group C (
). There was no difference in the incidence of adverse reactions among the 3 groups, and the LOS in group C was shorter than those in groups A and B (
). Conclusion. EPNS can effectively improve the lung function of patients with COPD combined with RF and reduce the inflammation and OS damage. It can effectively improve the therapeutic effect of patients and has great application prospects in the treatment of COPD combined with RH in the future.
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Flordelís Lasierra JL, Montejo González JC, López Delgado JC, Zárate Chug P, Martínez Lozano-Aranaga F, Lorencio Cárdenas C, Bordejé Laguna ML, Maichle S, Terceros Almanza LJ, Trasmonte Martínez MV, Mateu Campos L, Servià Goixart L, Vaquerizo Alonso C, Vila García B. Enteral Nutrition in Critically Ill Patients Under Vasoactive Drug Therapy. The NUTRIVAD Study. JPEN J Parenter Enteral Nutr 2022; 46:1420-1430. [PMID: 35274345 DOI: 10.1002/jpen.2371] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/18/2022] [Accepted: 03/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients. METHODS This prospective observational study was conducted in 23 ICUs over 30 months. Inclusion criteria were a need for VAD and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for at least 48 h of mechanical ventilation, an estimated life expectancy longer than 72 h, and at least 72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy and safety data were collected. An independent research group conducted the statistical analysis. RESULTS Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 μg/kg/min (95%CI: 0.63-0.8) targeting a mean arterial pressure of 68 mmHg (95%CI: 67-70) during the first 48 h. EN was started 34 h (95%CI: 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 Kcal (95%CI: 1098-1220) and 55.6 g (52.4-58.7) respectively. Daily energy balance during EN/patient/day was -432 (95%CI: -496 to -368). 154 (77%) patients experienced EN-related complications. However, severe complications such as mesenteric ischemia were recorded in only 1 patient (0.5%). CONCLUSIONS EN in these patients seems feasible, safe and unrelated to serious complications. Reaching the energy target only through EN is difficult. CLINICAL RELEVANCY STATEMENT Enteral nutrition (EN) in critically ill patients requiring vasoactive drugs (VAD) is currently a subject of controversy. Factors such as when to start EN, dosing, monitoring, or whether to avoid EN altogether are a real challenge because of its link to a risk of bowel ischemia. We describe our experience with EN in 200 critically ill patients on mechanical ventilation and requiring VAD. Under adequate supervision, EN proved feasible and safe. Our findings require confirmation in clinical intervention trials. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- José Luis Flordelís Lasierra
- Intensive Care Medicine Service. Research Institute Hospital 12 de Octubre (i+12), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Carlos Montejo González
- Intensive Care Medicine Service. Research Institute Hospital 12 de Octubre (i+12), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Carlos López Delgado
- Intensive Care Medicine Department. L'Hospitalet de Llobregat, Hospital Universitari de Bellvitge, (Barcelona), Spain
| | - Paola Zárate Chug
- Intensive Care Medicine Service, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - María Luisa Bordejé Laguna
- Intensive Care Medicine Service, Hospital Universitario Germans Trias i Pujol, Barcelona, Cataluña, Spain
| | - Silmary Maichle
- Intensive Care Medicine Service, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | - Lidón Mateu Campos
- Hospital General Universitario de Castellón, Comunidad Valenciana, Spain
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12
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Abstract
PURPOSE OF REVIEW Circulatory shock is associated with reduced splanchnic blood flow and impaired gut epithelial barrier function (EBF). Early enteral nutrition (EN) has been shown in animal models to preserve EBF. There are limited human data informing early EN in circulatory shock and critical care nutrition guidelines provide disparate recommendations regarding the optimal timing and dose. The purpose of this review is to describe the harms and benefits of early EN in circulatory shock by identifying and appraising recent human data. RECENT FINDINGS The cumulative risk of nonocclusive bowel ischemia and necrosis in patients with circulatory shock is no higher than 0.3% across observational and randomized controlled trial-level data, and whether the risk is increased by EN delivery remains uncertain. Observational data suggest that early EN in circulatory shock is associated with improved clinical outcomes but data from robust randomized controlled trials remain equivocal, so the optimal timing and dose remain unknown. SUMMARY Based on the best available data, initiating restrictive dose EN into the stomach after initial resuscitation in patients with circulatory shock does not appear to be harmful. In fact, early EN may preserve EBF and improve clinical outcomes.
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Affiliation(s)
- Anuj Shukla
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marianne Chapman
- Intensive Care Unit, Royal Adelaide Hospital; Clinical Professor, School of Medicine, University of Adelaide, Adelaide, Australia
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13
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Eisa M, McClave SA, Suliman S, Wischmeyer P. How Differences in the Disease Process of the COVID-19 Pandemic Pose Challenges to the Delivery of Critical Care Nutrition. Curr Nutr Rep 2021; 10:288-299. [PMID: 34676507 PMCID: PMC8530202 DOI: 10.1007/s13668-021-00379-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW The COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support. RECENT FINDINGS Prolonged hyperinflammation, unlike any previously described pattern of response to injury, causes metabolic perturbations and deterioration of nutritional status. High ventilatory demands, hypercoagulation with the risk of bowel ischemia, and threat of aspiration in patients with little or no pulmonary reserve, thwart initial efforts to provide early enteral nutrition (EN). The obesity paradox is invalidated, tolerance of EN is limited, intensivists are reluctant to add supplemental parenteral nutrition (PN), and efforts to give sufficient nutritional therapy remain a low priority. The nature of the disease and difficulties providing traditional critical care nutrition lead to dramatic deterioration of nutritional status. Institutions should not rely on insufficient gastric feeding alone but focus instead on redoubling efforts to provide postpyloric deep duodenal/jejunal EN or re-examine the role of supplemental PN in this population of patients with such severe critical illness.
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Affiliation(s)
- Mohamed Eisa
- grid.266623.50000 0001 2113 1622Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 S. Jackson St, Louisville, KY 40202 USA
| | - Stephen A. McClave
- grid.266623.50000 0001 2113 1622Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, 550 S. Jackson St, Louisville, KY 40202 USA
| | - Sally Suliman
- Division of Pulmonary, Critical Care & Sleep Disorders Medicine, Louisville, USA
| | - Paul Wischmeyer
- grid.189509.c0000000100241216Division of Anesthesiology and Critical Care Medicine, Duke University Hospital, Durham, North Carolina USA
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14
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Al-Dorzi HM, Arabi YM. Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers. Nutr Clin Pract 2020; 36:88-97. [PMID: 33373481 DOI: 10.1002/ncp.10621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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15
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Davis RC, Durham LA, Kiraly L, Patel JJ. Safety, Tolerability, and Outcomes of Enteral Nutrition in Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2020; 36:98-104. [PMID: 33078433 DOI: 10.1002/ncp.10591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/31/2020] [Accepted: 09/20/2020] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a supportive care system for patients with respiratory or cardiac failure. Patients requiring ECMO are at risk for significant inflammation, prolonged hospitalization, and acquired malnutrition and sarcopenia. Societal guidelines recommend early enteral nutrition in critically ill patients; however, in this population, optimal timing and dose of nutrition remains unknown and fear of reduced splanchnic perfusion, delayed gastric emptying, and bowel ischemia poses a barrier to appropriate energy and protein intake. This narrative review intends to provide an overview of ECMO, highlight the rationale for nutrition support in this population, and review the safety, tolerability, and outcomes associated with enteral nutrition during ECMO.
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Affiliation(s)
- Robert C Davis
- Clinical Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laszlo Kiraly
- Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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16
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Patel JJ, Martindale RG, McClave SA. Relevant Nutrition Therapy in COVID-19 and the Constraints on Its Delivery by a Unique Disease Process. Nutr Clin Pract 2020; 35:792-799. [PMID: 32786117 PMCID: PMC7436662 DOI: 10.1002/ncp.10566] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Worldwide, as of July 2020, >13.2 million people have been infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The spectrum of coronavirus disease 2019 (COVID-19) ranges from mild illness to critical illness in 5% of cases. The population infected with SARS-CoV-2 requiring an intensive care unit admission often requires nutrition therapy as part of supportive care. Although the various societal guidelines for critical care nutrition meet most needs for the patient with COVID-19, numerous factors, which impact the application of those guideline recommendations, need to be considered. Since the SARS-CoV-2 virus is highly contagious, several key principles should be considered when caring for all patients with COVID-19 to ensure the safety of all healthcare personnel involved. Management strategies should cluster care, making all attempts to bundle patient care to limit exposure. Healthcare providers should be protected, and the spread of SARS-CoV-2 should be limited by minimizing procedures and other interventions that lead to aerosolization, avoiding droplet exposure through hand hygiene and use of personal protective equipment (PPE). PPE should be preserved by decreasing the number of individuals providing direct patient care and by limiting the number of patient interactions. Enteral nutrition (EN) is tolerated by the majority of patients with COVID-19, but a relatively low threshold for conversion to parenteral nutrition should be maintained if increased exposure to the virus is required to continue EN. This article offers relevant and practical recommendations on how to optimize nutrition therapy in critically ill patients with COVID-19.
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Affiliation(s)
- Jayshil J. Patel
- Division of Pulmonary & Critical Care MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | - Robert G. Martindale
- Division of Gastrointestinal and General SurgeryOregon Health Sciences UniversityPortlandOregonUSA
| | - Stephen A. McClave
- Division of GastroenterologyHepatologyand NutritionUniversity of LouisvilleLouisvilleKentuckyUSA
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Nakayama H, Nishimoto Y, Hotta K, Sato Y. Safety of Early Enteral Nutrition for Cardiac Medical Critically Ill Patients - A Retrospective Observational Study. Circ Rep 2020; 2:560-564. [PMID: 33693181 PMCID: PMC7932810 DOI: 10.1253/circrep.cr-20-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Early intervention with enteral nutrition (EN) is the standard of care in many medical intensive care units (ICUs). However, few studies have addressed the use of early EN for critically ill patients in the cardiac ICU (CICU). In this study we explored the indications for early EN for patients admitted to a CICU. Methods and Results: This retrospective observational study included 63 consecutive patients admitted to the CICU who were diagnosed with cardiovascular disease. Early EN was initiated in these patients as per the hospital's nutrition protocol. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at admission were 18.8 and 9.1, respectively. All patients were admitted to the medical CICU with a diagnosis of cardiovascular disease and/or cardiopulmonary arrest. Enteral feeding was initiated in 59 patients (94%) within 5 days of admission. Fifty-two patients (83%) achieved the energy intake goal at Day 7 of their CICU admission either by enteral feeding or oral intake; 49 patients (78%) survived to time of discharge. The patients experienced several minor complications, including minor reflux (4 patients; 6%) and diarrhea (8 patients; 13%). None of the patients developed aspiration pneumonia or bowel ischemia. Conclusions: The present retrospective observational study indicates that early EN for critically ill patients in a medical CICU can be achieved safely with no major complications.
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Affiliation(s)
- Hiroyuki Nakayama
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
| | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
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Martindale R, Patel JJ, Taylor B, Arabi YM, Warren M, McClave SA. Nutrition Therapy in Critically Ill Patients With Coronavirus Disease 2019. JPEN J Parenter Enteral Nutr 2020; 44:1174-1184. [PMID: 32462719 PMCID: PMC7283713 DOI: 10.1002/jpen.1930] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023]
Abstract
In the midst of a coronavirus disease 2019 (COVID-19) pandemic, a paucity of data precludes derivation of COVID-19-specific recommendations for nutrition therapy. Until more data are available, focus must be centered on principles of critical care nutrition modified for the constraints of this disease process, ie, COVID-19-relevant recommendations. Delivery of nutrition therapy must include strategies to reduce exposure and spread of disease by providing clustered care, adequate protection of healthcare providers, and preservation of personal protective equipment. Enteral nutrition (EN) should be initiated early after admission to the intensive care unit (ICU) using a standard isosmolar polymeric formula, starting at trophic doses and advancing as tolerated, while monitoring for gastrointestinal intolerance, hemodynamic instability, and metabolic derangements. Intragastric EN may be provided safely, even with use of prone-positioning and extracorporeal membrane oxygenation. Clinicians should have a lower threshold for switching to parenteral nutrition in cases of intolerance, high risk of aspiration, or escalating vasopressor support. Although data extrapolated from experience in acute respiratory distress syndrome warrants use of fiber additives and probiotic organisms, the lack of benefit precludes a recommendation for micronutrient supplementation. Practices that increase exposure or contamination of equipment, such as monitoring gastric residual volumes, indirect calorimetry to calculate requirements, endoscopy or fluoroscopy to achieve enteral access, or transport out of the ICU for additional imaging, should be avoided. At all times, strategies for nutrition therapy need to be assessed on a risk/benefit basis, paying attention to risk for both the patient and the healthcare provider.
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Affiliation(s)
- Robert Martindale
- Department of SurgeryOregon Health and Science UniversityPortlandOregonUSA
| | - Jayshil J. Patel
- Division of Pulmonary & Critical Care MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | | | - Yaseen M. Arabi
- King Abdullah International Medical Research CenterKing Saud Din Abdulaziz University for Health SciencesRiyadhSaudi Arabia
| | - Malissa Warren
- Department of SurgeryOregon Health and Science University and Portland VA Health Care CenterPortlandOregonUSA
| | - Stephen A. McClave
- Division of Gastroenterology Hepatology and NutritionSchool of MedicineUniversity of LouisvilleLouisvilleKentuckyUSA
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