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Sumritpradit P, Shantavasinkul PC, Ungpinitpong W, Noorit P, Gajaseni C. Effect of high-protein peptide-based formula compared with isocaloric isonitrogenous polymeric formula in critically ill surgical patient. World J Gastrointest Surg 2024; 16:1765-1774. [PMID: 38983323 PMCID: PMC11230013 DOI: 10.4240/wjgs.v16.i6.1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Malnutrition is common in critically ill patients, and it is associated with an increased risk of complications. Early enteral nutrition with adequate caloric and protein intake is critical nevertheless it is difficult to achieve. Peptide-based formulas have been shown to be beneficial in patients with feeding intolerance. However, there are limited studies showing the efficacy and safety of high-protein peptide-based formula in critically ill surgical patients. AIM To determine the effects of a high-protein peptide formulation on gastrointestinal tolerance, nutritional status, biochemical changes, and adverse events in patients in the surgery intensive care unit (SICU) compared to an isocaloric isonitrogenous standard polymeric formulation. METHODS This study was a multi-center double-blind, randomized controlled trial. We enrolled adult patients in the surgical intensive care unit, age ≥ 15 years and expected to receive enteral feeding for at least 5-14 d post-operation. They were randomly assigned to receive either the high-protein peptide-based formula or the isocaloric isonitrogenous standard formula for 14 d. Gastric residual volume (GRV), nutritional status, body composition and biochemical parameters were assessed at baseline and on days 3, 5, 7, 9, 11, and 14. RESULTS A total of 19 patients were enrolled, 9 patients in the peptide-based formula group and 10 patients in the standard formula group. During the study period, there were no differences of the average GRV, body weight, body composition, nutritional status and biochemical parameters in the patients receiving peptide-based formula, compared to the standard regimen. However, participants in the standard formula lost their body weight, body mass index (BMI) and skeletal muscle mass significantly. While body weight, BMI and muscle mass were maintained in the peptide-based formula, from baseline to day 14. Moreover, the participants in the peptide-based formula tended to reach their caloric target faster than the standard formula. CONCLUSION The study emphasizes the importance of early nutritional support in the SICU and showed the efficacy and safety of a high-protein, peptide-based formula in meeting caloric and protein intake targets while maintaining body weight and muscle mass.
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Affiliation(s)
- Preeda Sumritpradit
- Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Prapimporn Chattranukulchai Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
- Graduate Program in Nutrition, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | | | - Pinit Noorit
- Department of Surgery, Chonburi Hospital, Chonburi 20000, Thailand
| | - Chotip Gajaseni
- Department of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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EKMEN MÖ, UYANIKOĞLU A, EFE SC, SARİ S, YENİCE N. Perkütan Enteral Gastrostomi Kullanımı ve Hasta Özelliklerinin Değerlendirilmesi: Tek Merkez Deneyimi. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.907632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Amaç: Perkütanöz endoskopik gastrostomi, sıklıkla beslenme problemi olan ve uzun süreli tüple beslenme ihtiyacı olan bireylerde kullanılmaktadır. Bu çalışmanın amacı, öncelikle, kliniğimizde yıllar içinde değişen perkütanöz endoskopik gastrostomi kullanımı ve hasta özelliklerini ve PEG işlemi öncesi ve sonrası bazı biyokimyasal belirteçlerdeki değişimleri ve anlamlı olup olmadığını saptamaktı.
Gereç ve Yöntem: Ağustos 2014-Ağustos 2019 tarihleri arası merkezimizde perkütanöz endoskopik gastrostomi uygulanan 170 hastanın verileri retrospektif olarak değerlendirildi. Demografik özellikleri kaydedildikten sonra PEG öncesi ve PEG sonrası glukoz,üre, kreatinin, alt, ggt,albümin,kalsiyum,magnezyum,crp, wbc, hb,plt,ınr değerleri karşılaştırılmış ve değişkenlerin analizinde SPSS programı kullanıldı
Bulgular: Çalışmaya dahil edilen 170 hastanın %52,3’ü kadın,%47,7’si erkekti. Hastaların ortanca yaşı 72 yıldı (minimum:17 yıl, maksimum: 104 yıl). 2014 yılından başlayarak PEG uygulanan hasta sayısı 2019’e kadar yıllara göre sırasıyla 14,20,22,25,44,45 idi(p=0,03) yillara göre PEG açılma sıklığında istatiski olarak anlamlı artış izlenmiştir. Hastaların PEG endikasyonu değerlendirilmiş olup serebrovasküler olay (SVO) her yıl için en sık sebepti, n:76 (%44,6).Diğer PEG endikasyonlarını sırasıyla maligniteler n:29(%17),hipoksik iskemik ensefalopati n:17(%10), diğer sebepler n:48(%28,4) olarak görülmekteydi.Hastaların PEG açıldıktan sonra hastanede kalış süresi ortalama 11,3 gün olarak saptandı(Tablo 1).PEG öncesi ve sonrası bakılan değerlerınden üre,kreatinin ve magnezyum değerlerinde istastistiksel olarak değişme tespit edilmiştir(p
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Affiliation(s)
- Mehmet Önder EKMEN
- HARRAN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, GASTROENTEROLOJİ BİLİM DALI
| | - Ahmet UYANIKOĞLU
- HARRAN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, GASTROENTEROLOJİ BİLİM DALI
| | - Savaş Cumali EFE
- HARRAN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, GASTROENTEROLOJİ BİLİM DALI
| | - Süleyman SARİ
- HARRAN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI
| | - Necati YENİCE
- HARRAN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, GASTROENTEROLOJİ BİLİM DALI
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Comparison of the Initiation Time of Enteral Nutrition for Critically Ill Patients: At Admission vs. 24 to 48 Hours after Admission. Emerg Med Int 2021; 2021:3047732. [PMID: 34580613 PMCID: PMC8464429 DOI: 10.1155/2021/3047732] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/06/2021] [Indexed: 01/03/2023] Open
Abstract
Objective To investigate the better time of initiation of enteral nutrition for critically ill patients, such as at admission or 24 to 48 hours after admission. Methods This was a prospective, randomized, parallel-controlled, single-blind, interventional clinical trial. A total of 100 patients admitted to the intensive care unit (ICU) of our hospital between January 2017 and December 2018 were recruited in this study. These patients had been divided into the control group or intervention group by a computer-generated random number table, and each group had 50 patients. For the control group, a gastric tube was inserted to start enteral nutrition at 24 to 48 hours after admission. For the intervention group, a nasojejunal tube was placed to start enteral nutrition at admission. The main endpoints included serum albumin and prealbumin at admission and on days 3, 7, and 14 after admission, length of ICU stay, ventilator time, and complications such as diarrhea, gastric retention, esophageal reflux, and pulmonary infection. Results The results showed that serum albumin and prealbumin were significantly higher in the intervention group than in the control group (P < 0.05). The length of ICU stay (P < 0.05) and ventilator time (P < 0.05) were both significantly shorter in the intervention group than in the control group. The incidences of gastric retention, esophageal reflux, and pulmonary infection were significantly lower in the intervention group than those in the control group (P < 0.05). Conclusion In the absence of contraindications, enteral nutrition can be initiated immediately after admission to the ICU (within 6 hours), and feeding nasojejunal tube is recommended. It can improve the nutritional status and prognosis of critical patients, improve the feeding effect, shorten the length of stay in the ICU and the use of the ventilator, and reduce the incidence of complications.
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KARAKOÇ E, TAKTAKOĞLU O, ERDOGAN M. Comparison of energy consumptions measured by metabolic monitor with standard equations in intensive care patients. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.865721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Balekuduru AB, Bongu SS, Mandalapu NB, Ramachandraiah G, Khemka VK, Subbaraj SB. Fluoroscopy-Assisted Percutaneous Endoscopic Gastrostomy (F-PEG)—Single-Center Experience and Outcome. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1716580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractBackground Gastrointestinal route is considered for feeding in subjects who are unable to swallow, either as a temporary or permanent option. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode for long-term enteral nutrition. The aim was to study the outcome of protocol-based PEG placement in a tertiary medical center.Materials and Methods All the patients who underwent PEG placement between January 2017 and December 2019 were included in the retrospective study. Study variables were entered into a uniform structured proforma. The procedure was done by two people using Ponsky-Gauderer pull-technique. Fluoroscopy guidance was considered for placement in special situations. Post-procedure, all the patients were regularly followed as per protocol to evaluate for adverse events.Results One hundred and eighteen patients with placement of PEG were included in the study. The mean age of the patients was 49.6 ± 7 years with 67.8% males. The most common indication of PEG was inability to swallow associated with head injury (43, 36.4%), followed by carcinoma esophagus (35, 29.8%) and stroke (24, 20.3%). Fluoroscopy was useful in 38 (32%) for PEG site identification. Tube dislodgement (16, 13.5%) and aspiration pneumonia (20, 16.9%) were the common adverse events. Age more than 60 years and dysphagia in neurologic disorders accounted for more than 60% of adverse events. Forty-nine (42%) of the PEG patients expired due to either primary illness or due to sepsis after a median time of 139 days (range: 32–288 days). There was no difference in the survival in patients with or without PEG-related complications (p = 0. 74).Conclusions Fluoroscopy assistance helps in accurate PEG placement in one third. Age > 60 years and dysphagia in neurologic disorders were independent risk factors associated with PEG tube complications.
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Affiliation(s)
| | - Shruti Sagar Bongu
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
| | | | | | - Vinit Kumar Khemka
- Department of Gastroenterology, M.S. Ramaiah Hospitals, Bangalore, Karnataka, India
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Pih GY, Na HK, Hong SK, Ahn JY, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical Outcomes of Percutaneous Endoscopic Gastrostomy in the Surgical Intensive Care Unit. Clin Endosc 2020; 53:705-716. [PMID: 32229800 PMCID: PMC7719425 DOI: 10.5946/ce.2019.196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/15/2020] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Percutaneous endoscopic gastrostomy (PEG) is usually performed on patients with chronic underlying diseases in the general ward (GW). This study evaluated the clinical outcomes of PEG performed on patients in the surgical intensive care unit (SICU) compared with those of PEG performed in the GW.
Methods The medical records of 27 patients in the SICU and 263 in the GW, who underwent PEG between January 2013 and July 2017, were retrospectively reviewed.
Results The median age of the 27 SICU patients was 66 years, and their median body mass index was 21.1 kg/m2. In the SICU group, the median baseline Sequential Organ Failure Assessment (SOFA) score was 4, and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 16. The median interval between surgery and PEG in SICU patients was 30 days, with a PEG failure rate of 3.7%. Acute complications in SICU patients included bleeding (7.4%) and ileus (11.1%), while chronic complications included aspiration pneumonia (7.4%) and tube obstruction (3.7%). The rates of acute and chronic complications did not differ significantly between the SICU and GW groups. The 30-day mortality rate was 14.8% in SICU patients and 5.3% in GW patients (p=0.073).
Conclusions PEG is a safe and feasible method of enteral feeding for critically ill patients who require ICU care after surgery.
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Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Nutritional Support Team, Asan Medical Center, Seoul, Korea
| | - Suk-Kyung Hong
- Nutritional Support Team, Asan Medical Center, Seoul, Korea.,Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Li K, Li X, Si W, Cui Y, Xia H, Sun X, Song X, Liang H. Preoperative and operation-related risk factors for postoperative nosocomial infections in pediatric patients: A retrospective cohort study. PLoS One 2019; 14:e0225607. [PMID: 31869341 PMCID: PMC6927644 DOI: 10.1371/journal.pone.0225607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/07/2019] [Indexed: 12/02/2022] Open
Abstract
Background Pediatric patients undergoing invasive operations bear extra risk of developing nosocomial infections (NIs). However, epidemiological evidence of the underlying risk factors, which is needed for early prevention, remains limited. Methods Using data from the electronic medical records and the NI reporting system of a tertiary pediatric hospital, we conducted a retrospective analysis to identify preoperative and operation-related risk factors for postoperative NIs. Multivariable accelerated failure time models were fitted to select independent risk factors. The performance of these factors in risk stratification was examined by comparing the empirical risks between the model-defined low- and high-risk groups. Results A total of 18,314 children undergoing invasive operations were included for analysis. After a follow-up period of 154,700 patient-days, 847 postoperative NIs were diagnosed. The highest postoperative NI rate was observed for operations on hemic and lymphatic system. Surgical site infections were the NI type showing the highest overall risk; however, patients were more likely to develop urinary tract infections in the first postoperative week. Older age, higher weight-for-height z-score, longer preoperative ICU stay, preoperative enteral nutrition, same-day antibiotic prophylaxis, and higher hemoglobin level were associated with delayed occurrence of postoperative NIs, while longer preoperative hospitalization, longer operative duration, and higher American Society of Anesthesiologists score showed acceleration effects. Risk stratification based on these factors in an independent patient population was moderate, resulting in a high-risk group in which 72% of the postoperative NIs were included. Conclusions Our findings suggest that pediatric patients undergoing invasive operations and at high risk of developing postoperative NIs are likely to be identified using basic preoperative and operation-related risk factors, which together might lead to moderately accurate risk stratification but still provide valuable information to guide early and judicious prevention.
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Affiliation(s)
- Kuanrong Li
- Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xiaojun Li
- Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenyue Si
- Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yanqin Cui
- Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huimin Xia
- Guangdong Province Key Laboratory of Structural Birth Defects, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xin Sun
- Department of Medical Administration, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xingrong Song
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail:
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Fuentes Padilla P, Martínez G, Vernooij RWM, Urrútia G, Roqué i Figuls M, Bonfill Cosp X. Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults. Cochrane Database Syst Rev 2019; 2019:CD012340. [PMID: 31684690 PMCID: PMC6820694 DOI: 10.1002/14651858.cd012340.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit. OBJECTIVES To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults. SEARCH METHODS We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This included individuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition. DATA COLLECTION AND ANALYSIS Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia. AUTHORS' CONCLUSIONS Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.
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Affiliation(s)
- Paulina Fuentes Padilla
- Iberoamerican Cochrane CentreC/ Sant Antoni Maria Claret 167Pavelló 18 Planta 0BarcelonaBarcelonaSpain08025
- Universidad de AntofagastaFaculty of Medicine and DentistryAntofagastaChile
- Servicio de Salud AntofagastaAntofagastaChile
| | - Gabriel Martínez
- Iberoamerican Cochrane CentreC/ Sant Antoni Maria Claret 167Pavelló 18 Planta 0BarcelonaBarcelonaSpain08025
- Universidad de AntofagastaFaculty of Medicine and DentistryAntofagastaChile
- Servicio de Salud AntofagastaAntofagastaChile
| | - Robin WM Vernooij
- University Medical Center UtrechtDepartment of Nephrology and Hypertension and Julius Center for Health Sciences and Primary CareHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
- Universitat Autònoma de BarcelonaSant Antoni Maria Claret, 167Pavilion 18 (D‐13)BarcelonaCatalunyaSpain08025
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Karhof S, Haverkort M, Simmermacher R, Hietbrink F, Leenen L, van Wessem K. Underlying disease determines the risk of an open abdomen treatment, final closure, however, is determined by the surgical abdominal history. Eur J Trauma Emerg Surg 2019; 47:113-120. [PMID: 31451863 PMCID: PMC7851030 DOI: 10.1007/s00068-019-01205-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Temporary abdominal closure is frequently used in several situations such as abbreviated surgery in damage control situations or when closing is impossible due to organ distention or increased abdominal pressure. The ultimate goal is to eventually close the fascia; however, little is known about factors predicting abdominal closure. The purpose of this study was to identify characteristics associated with the need for open abdomen as well as indicating the possibility of delayed fascial closure after a period of open abdominal treatment. METHODS A retrospective review of all patients that underwent midline laparotomy between January 2008 and December 2012 was performed. Both factors predicting open abdominal treatment and possibility to close the fascia afterwards were identified and analyzed by univariate and multivariate analyses. RESULTS 775 laparotomies in 525 patients (60% male) were included. 109 patients (21%) had an open abdomen with a mortality rate of 27%. Male gender and acidosis were associated with open abdominal treatment. In 54%, the open abdomen could be closed by delayed fascial closure. The number of laparotomies both before and during temporary abdominal treatment was associated with failure of closure. CONCLUSION In this study, male sex and physiological derangement, reflected by acidosis, were independent predictors of open abdominal treatment. Furthermore, the success of delayed fascial closure depends on number of abdominal surgical procedures. Moreover, based on our experiences, we suggest to change modalities early on, to prevent multiple fruitless attempts to close the abdomen.
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Affiliation(s)
- Steffi Karhof
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Mark Haverkort
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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11
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Adjemian D, Arendt BM, Allard JP. Assessment of parenteral nutrition prescription in Canadian acute care settings. Nutrition 2017; 49:7-12. [PMID: 29571609 DOI: 10.1016/j.nut.2017.11.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 11/11/2017] [Accepted: 11/17/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) prescription can be challenging in patients with complex conditions and has potential complications. OBJECTIVE To assess PN prescription, monitoring, and PN-related complications in a Canadian acute care setting. METHODS This was a prospective cohort study in which patients receiving PN were assessed by an auditor for nutritional status, PN-related prescription, monitoring, and complications. In addition, length of stay and mortality were recorded. RESULTS 147 patients (mean ± SD 56.1 ± 16.4 y) with complex diseases (Charlson comorbidity index, median [p25-p75] 2 [1-4]) were enrolled. Before starting PN, 18.6%, 63.9%, and 17.5% of patients were classified as subjective global assessment A, B, and C, respectively. Body mass index remained unchanged during the period on PN. On average, 89% and 73% of patients received <90% of their energy and protein requirements, respectively, but 65% received oral or enteral nutrition at some point during PN. The average daily energy provided by PN increased and stabilized on day 10, reaching 87.2 ± 20.1% of the requirements. Line sepsis (6.8% of patients) and hyperglycemia (6.9%) were the most common complications. The overall mortality was 15.6%. For those alive, length of stay was 30 (range: 4-268) d. PN was discontinued because of transitioning to an oral diet (56.6%), enteral nutrition (17.6%), home PN (14.7%), palliative care (5.1%), death (4.4%), or other (1.5%). CONCLUSION Most patients were malnourished at the start of PN. Energy and protein provided from PN were less than requirements, and the goals were reached with delay. Mortality was high, possibly as a result of complex diseases.
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Affiliation(s)
- Daniela Adjemian
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Bianca M Arendt
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Johane P Allard
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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12
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Effects of Synbiotic2000™ Forte on the Intestinal Motility and Interstitial Cells of Cajal in TBI Mouse Model. Probiotics Antimicrob Proteins 2017; 9:172-181. [PMID: 28303478 DOI: 10.1007/s12602-017-9266-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The main objective of this study was to investigate the effects of Synbiotic2000™ Forte on the intestinal motility and interstitial cells of Cajal (ICC) in traumatic brain injury (TBI) mouse model. Kunming mice were randomly divided into sham operation group (S group), enteral nutrition group with TBI (E group), and Synbiotic2000™ Forte group with TBI (P group). The contractile activity of the intestinal smooth muscle, densities and ultrastructure of the ICC, kit protein concentration, weight, and defecation of mice were monitored and analyzed. TBI markedly suppressed contractile activity of the intestinal smooth muscle (P < 0.01), which led to a reduction of defecation (P < 0.01) and weight (P < 0.01). However, application of Synbiotic2000™ Forte significantly improved contractile activity of the small intestine (P < 0.01), which may be related to protective effects to the interstitial cells of Cajal, smooth muscle cells, and enteric neurons. TBI impaired ICC networks and densities (P < 0.01), events that were protected by the application of Synbiotic2000™ Forte. Synbiotic2000™ Forte may attenuate TBI-mediated inhibition of the kit protein pathway. Synbiotic2000™ Forte may improve intestinal motility and protect the ICC in the TBI mouse. These findings provide a novel support for the application of Synbiotic2000™ Forte in intestinal motility disturbance after TBI.
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Abstract
Critical care medicine is a young specialty that has experienced an expansion of research efforts in the last decade. Many physiologic and therapeutic principles or “dogmas” have been challenged, resulting in major “shifts” and minor “drifts” in thinking. This article reviews the available literature about some of these important and sometimes controversial changes, with emphasis on the practical implications of the concepts. Specific areas discussed include supply-dependent oxygen consumption in critical illness, manipulation of the cytokine cascade in sepsis, ventilation in the acute respiratory distress syndrome (ARDS), blood transfusion in the critically ill, the concept of the multiple organ dysfunction syndrome (MODS), the need for nutritional support in the critically ill, and others. Many of the changes discussed involve the recognition that the host response to a severe insult is exceedingly complex, and the understanding of this response and the effects of it at a tissue and cellular level are incomplete. As a result, the ability to impact the outcome of sepsis and MODS has thus far been disappointing, with the possible exception of “lung-protective” ventilation. The final challenge in critical care medicine is to gain information that will allow the practitioner to better understand, prevent, and treat the complex events that result in organ and cellular dysfunction. Future changes in dogma are welcome if they help achieve these goals.
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Affiliation(s)
- Ari Robin Joffe
- Department of Pediatrics, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada.
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14
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Murthy TA, Rangappa P, Anil BJ, Jacob I, Rao K. Postoperative nutrition practices in abdominal surgery patients in a tertiary referral hospital Intensive Care Unit: A prospective analysis. Indian J Crit Care Med 2016; 20:319-22. [PMID: 27390454 PMCID: PMC4922283 DOI: 10.4103/0972-5229.183910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Benefit of early enteral feeds in surgical patients admitted to Intensive Care Units (ICUs) has been emphasized by several studies. Apprehensions about anastomotic leaks in gastrointestinal surgical patients prevent initiation of early enteral nutrition (EN). The impact of these practices on outcome in Indian scenario is less studied. Aims: This study compares the impact of early EN (within 48 h after surgery) with late EN (48 h postsurgery) on outcomes in abdominal surgical ICU patients. Settings and Design: Postabdominal surgery patients admitted to a tertiary referral hospital ICU over a 2-year period were analyzed. Methods: Only patients directly admitted to ICU after abdominal surgery were included in this study. ICU stay>3 days was considered as prolonged; with average ICU length of stay (LOS) for this ICU being 3 days. The primary outcome was in-patient mortality. ICU LOS, hospital LOS, infection rates, and ventilator days were secondary outcome measures. Acute Physiology and Chronic Health Evaluation II scores were calculated. SPSS and Microsoft Excel were used for analysis. Results: Of 91 ICU patients included, 58 received early EN and 33 late EN. Hospital LOS and infection rates were less in early EN group. Use of parenteral nutrition (odds ratio [OR] 5.25, 95% confidence interval (CI); P = 0.003) and number of nil-per-oral days (OR 8.25, 95% CI; P ≤ 0.001) were other predictors of prolonged LOS. Conclusions: Early EN in postabdominal surgery ICU patients was associated with reduced hospital LOS and infection rates. ICU LOS, duration of mechanical ventilation and mortality rates did not vary.
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Affiliation(s)
| | - Pradeep Rangappa
- Intensive Care Unit, Columbiaasia Referral Hospital, Yeshwantpur, Bengaluru, Karnataka, India
| | - B J Anil
- General Manager, Pharmacy, IMO, Columbiaasia Hospitals, Bengaluru, Karnataka, India
| | - Ipe Jacob
- Intensive Care Unit, Columbiaasia Referral Hospital, Yeshwantpur, Bengaluru, Karnataka, India
| | - Karthik Rao
- Intensive Care Unit, Columbiaasia Referral Hospital, Yeshwantpur, Bengaluru, Karnataka, India
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Stewart ML, Biddle M, Thomas T. Evaluation of current feeding practices in the critically ill: A retrospective chart review. Intensive Crit Care Nurs 2016; 38:24-30. [PMID: 27395368 DOI: 10.1016/j.iccn.2016.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 04/22/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Worldwide, malnutrition is an important issue in the care of the critically ill which is associated with increased costs of care and poor patient outcomes. OBJECTIVES To evaluate the current state of enteral nutrition in the critically ill in the U.S. in comparison to international practices. RESEARCH METHODOLOGY/DESIGN A retrospective chart audit was performed utilising a 10% random sample of patients admitted to the Pulmonary Medicine Service at an academic medical center in the U.S. from 1/1/11 to 12/31/11. A total of 69 charts were audited. OUTCOME MEASURES Outcome measures included time to initiation of feeds, prescribed versus received protein and energy on day three, prokinetic use and markers of nutritional status. RESULTS Delayed time to feeding, greater than 48hours after ICU admission, was present in 66.7% of the sample. On day three only 9% of the sample was receiving 80% or more of the prescribed protein or energy. These findings are similar to those found internationally. CONCLUSION Critically ill patients continue to experience delays in enteral feeding initiation and are frequently not meeting nutrition targets. Interventions aimed at improving nutrition delivery in the intensive care unit should be a focus of quality care both in the U.S. and internationally.
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Affiliation(s)
| | - Martha Biddle
- 525 College of Nursing, University of Kentucky, Lexington, KY 40536, USA.
| | - Travis Thomas
- University of Kentucky, Department of Clinical Sciences, College of Health Sciences, 209H CTW Building, 900 South Limestone, Lexington, KY 40536, USA.
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Creamer KM, Chan DS, Sutton C, DeLeon C, Moreno C, Shoupe BA. A Comprehensive Pediatric Inpatient Nutrition Support Package: A Multi-disciplinary Approach. Nutr Clin Pract 2016. [DOI: 10.1177/088453360101600409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Ochoa JB, Magnuson B, Swintowsky M, Loan T, Boulanger B, McClain C, Kearney P. Long-Term Reduction in the Cost of Nutritional Intervention Achieved by a Nutrition Support Service. Nutr Clin Pract 2016. [DOI: 10.1177/088453360001500404] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Joffe A, Anton N, Lequier L, Vandermeer B, Tjosvold L, Larsen B, Hartling L. Nutritional support for critically ill children. Cochrane Database Syst Rev 2016; 2016:CD005144. [PMID: 27230550 PMCID: PMC6517095 DOI: 10.1002/14651858.cd005144.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. This is an update of a review that was originally published in 2009. . OBJECTIVES The objective of this review was to assess the impact of enteral and parenteral nutrition given in the first week of illness on clinically important outcomes in critically ill children. There were two primary hypotheses:1. the mortality rate of critically ill children fed enterally or parenterally is different to that of children who are given no nutrition;2. the mortality rate of critically ill children fed enterally is different to that of children fed parenterally.We planned to conduct subgroup analyses, pending available data, to examine whether the treatment effect was altered by:a. age (infants less than one year versus children greater than or equal to one year old);b. type of patient (medical, where purpose of admission to intensive care unit (ICU) is for medical illness (without surgical intervention immediately prior to admission), versus surgical, where purpose of admission to ICU is for postoperative care or care after trauma).We also proposed the following secondary hypotheses (a priori), pending other clinical trials becoming available, to examine nutrition more distinctly:3. the mortality rate is different in children who are given enteral nutrition alone versus enteral and parenteral combined;4. the mortality rate is different in children who are given both enteral feeds and parenteral nutrition versus no nutrition. SEARCH METHODS In this updated review we searched: the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2); Ovid MEDLINE (1966 to February 2016); Ovid EMBASE (1988 to February 2016); OVID Evidence-Based Medicine Reviews; ISI Web of Science - Science Citation Index Expanded (1965 to February 2016); WebSPIRS Biological Abstracts (1969 to February 2016); and WebSPIRS CAB Abstracts (1972 to February 2016). We also searched trial registries, reviewed reference lists of all potentially relevant studies, handsearched relevant conference proceedings, and contacted experts in the area and manufacturers of enteral and parenteral nutrition products. We did not limit the search by language or publication status. SELECTION CRITERIA We included studies if they were randomized controlled trials; involved paediatric patients, aged one day to 18 years of age, who were cared for in a paediatric intensive care unit setting (PICU) and had received nutrition within the first seven days of admission; and reported data for at least one of the pre-specified outcomes (30-day or PICU mortality; length of stay in PICU or hospital; number of ventilator days; and morbid complications, such as nosocomial infections). We excluded studies if they only reported nutritional outcomes, quality of life assessments, or economic implications. Furthermore, we did not address other areas of paediatric nutrition, such as immunonutrition and different routes of delivering enteral nutrition, in this review. DATA COLLECTION AND ANALYSIS Two authors independently screened the searches, applied the inclusion criteria, and performed 'Risk of bias' assessments. We resolved discrepancies through discussion and consensus. One author extracted data and a second checked data for accuracy and completeness. We graded the evidence based on the following domains: study limitations, consistency of effect, imprecision, indirectness, and publication bias. MAIN RESULTS We identified only one trial as relevant. Seventy-seven children in intensive care with burns involving more than 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. We assessed the trial as having unclear risk of bias. We consider the quality of the evidence to be very low due to there being only one small trial. In the most recent search update we identified a protocol for a relevant randomized controlled trial examining the impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients; no results have been published. AUTHORS' CONCLUSIONS There was only one randomized trial relevant to the review question. Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.
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Affiliation(s)
- Ari Joffe
- University of Alberta and Stollery Children's HospitalDepartment of Pediatrics, Division of Pediatric Intensive CareOffice 3A3.078440‐ 112 StEdmontonABCanadaT6G 2B7
| | - Natalie Anton
- University of Alberta and Stollery Children's HospitalDepartment of Pediatrics, Division of Pediatric Intensive CareOffice 3A3.078440‐ 112 StEdmontonABCanadaT6G 2B7
| | - Laurance Lequier
- University of Alberta and Stollery Children's HospitalDepartment of Pediatrics, Division of Pediatric Intensive CareOffice 3A3.078440‐ 112 StEdmontonABCanadaT6G 2B7
| | - Ben Vandermeer
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health Evidence11405 ‐ 87 AvenueEdmontonABCanadaT6G 1C9
| | - Lisa Tjosvold
- University of AlbertaAlberta Research Centre for Child Health EvidenceAberhart Centre One, Room 942011402 University Ave.EdmontonABCanadaT6G 2J3
| | - Bodil Larsen
- Stollery Children's HospitalNutrition ServiceEdmontonABCanadaT6G 2B7
| | - Lisa Hartling
- University of AlbertaDepartment of Pediatrics and the Alberta Research Centre for Health Evidence11405 ‐ 87 AvenueEdmontonABCanadaT6G 1C9
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Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse 2015; 34:14-21; quiz 22. [PMID: 25086090 DOI: 10.4037/ccn2014243] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.
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Affiliation(s)
- Melissa L Stewart
- Melissa Stewart is a staff nurse in the medical intensive care unit at the University of Kentucky Chandler Medical Center in Lexington.
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20
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The olive oil-based lipid clinoleic blocks leukocyte recruitment and improves survival during systemic inflammation: a comparative in vivo study of different parenteral lipid emulsions. Mediators Inflamm 2015; 2015:757059. [PMID: 25767334 PMCID: PMC4341856 DOI: 10.1155/2015/757059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 12/16/2014] [Accepted: 12/29/2014] [Indexed: 12/15/2022] Open
Abstract
Although fish oil-based and olive oil-based lipid emulsions have been shown to exert anti-inflammatory functions, the immunomodulating properties of lipids are still controversial. Therefore, we investigated the anti-inflammatory effect of three different parenterally administered lipid emulsions in vivo: olive oil-based Clinoleic, fish oil-based Smoflipid, and soybean oil-based Lipofundin. We observed leukocyte recruitment in inflamed murine cremaster muscle using intravital microscopy and survival in a murine model of LPS-induced systemic inflammation and analyzed expression of leukocyte and endothelial adhesion molecules. Olive oil-based Clinoleic and fish oil-based Smoflipid profoundly inhibited leukocyte adhesion compared to Lipofundin during LPS-induced inflammation of the murine cremaster muscle. In the trauma model of cremaster muscle inflammation, Lipofundin was the only lipid emulsion that even augmented leukocyte adhesion. In contrast to Smoflipid and Lipofundin, Clinoleic effectively blocked leukocyte recruitment and increased survival during lethal endotoxemia. Flow chamber experiments and analysis of adhesion molecule expression suggest that both endothelial and leukocyte driven mechanisms might contribute to anti-inflammatory effects of Clinoleic. We conclude that the anti-inflammatory properties of Clinoleic are superior to those of Smoflipid and Lipofundin even during systemic inflammation. Thus, these results should stimulate further studies investigating parenteral lipids as an anti-inflammatory strategy in critically ill patients.
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Charles EJ, Petroze RT, Metzger R, Hranjec T, Rosenberger LH, Riccio LM, McLeod MD, Guidry CA, Stukenborg GJ, Swenson BR, Willcutts KF, O'Donnell KB, Sawyer RG. Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: a randomized controlled trial. Am J Clin Nutr 2014; 100:1337-43. [PMID: 25332331 PMCID: PMC4196484 DOI: 10.3945/ajcn.114.088609] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Proper caloric intake goals in critically ill surgical patients are unclear. It is possible that overnutrition can lead to hyperglycemia and an increased risk of infection. OBJECTIVE This study was conducted to determine whether surgical infection outcomes in the intensive care unit (ICU) could be improved with the use of hypocaloric nutritional support. DESIGN Eighty-three critically ill patients were randomly allocated to receive either the standard calculated daily caloric requirement of 25-30 kcal · kg(-1) · d(-1) (eucaloric) or 50% of that value (hypocaloric) via enteral tube feeds or parenteral nutrition, with an equal protein allocation in each group (1.5 g · kg(-1) · d(-1)). RESULTS There were 82 infections in the hypocaloric group and 66 in the eucaloric group, with no significant difference in the mean (± SE) number of infections per patient (2.0 ± 0.6 and 1.6 ± 0.2, respectively; P = 0.50), percentage of patients acquiring infection [70.7% (29 of 41) and 76.2% (32 of 42), respectively; P = 0.57], mean ICU length of stay (16.7 ± 2.7 and 13.5 ± 1.1 d, respectively; P = 0.28), mean hospital length of stay (35.2 ± 4.9 and 31.0 ± 2.5 d, respectively; P = 0.45), mean 0600 glucose concentration (132 ± 2.9 and 135 ± 3.1 mg/dL, respectively; P = 0.63), or number of mortalities [3 (7.3%) and 4 (9.5%), respectively; P = 0.72]. Further analyses revealed no differences when analyzed by sex, admission diagnosis, site of infection, or causative organism. CONCLUSIONS Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.
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Affiliation(s)
- Eric J Charles
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Robin T Petroze
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Rosemarie Metzger
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Tjasa Hranjec
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Laura H Rosenberger
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Lin M Riccio
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Matthew D McLeod
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Christopher A Guidry
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - George J Stukenborg
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Brian R Swenson
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Kate F Willcutts
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Kelly B O'Donnell
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
| | - Robert G Sawyer
- From the Department of Surgery, University of Virginia Health System, Charlottesville, VA (EJC, RTP, RM, TH, LHR, LMR, MDM, CAG, BRS, KFW, KBO, and RGS), and the Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA (GJS)
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Lottes Stewart M. Nutrition support protocols and their influence on the delivery of enteral nutrition: a systematic review. Worldviews Evid Based Nurs 2014; 11:194-9. [PMID: 24841717 DOI: 10.1111/wvn.12036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Malnutrition remains prevalent in critically ill adults and is associated with poor outcomes and increased cost of hospitalization. AIM To (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support based on a protocol have better outcomes than those who do not. METHODS CINHAL and PUBMED databases were searched utilizing keywords "model," "nutrition," intensive care," "algorithm," "critical care," "protocol," and "feeding guidelines." Selection criteria included original studies published in English with publication date between January 1, 2005, and December 31, 2010; a critically ill adult population; and level 1 or 2 studies. Studies were collected and reviewed by a single reviewer. Data extraction and quality assessment were assured utilizing a standardized form. A narrative description of results was provided due to variability in methods and outcome measures of included studies. RESULTS Ninety-nine studies emerged and 22 studies were considered for inclusion. Four studies were selected. Use of a nutrition support protocol was found to lead to increased efficacy in the delivery of nutrients via the enteral route. LINKING EVIDENCE TO ACTION The use of a nutrition support protocol appears to increase the efficacy of enteral nutrition delivery. Further research is needed to determine the effect of increased enteral nutrition adequacy on patient outcomes. The use of an evidenced-based protocol is recommended to improve protein and energy delivery in the critically ill.
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Cahill NE, Day AG, Cook D, Heyland DK. Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients. Implement Sci 2013; 8:140. [PMID: 24305039 PMCID: PMC4235036 DOI: 10.1186/1748-5908-8-140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 11/26/2013] [Indexed: 12/20/2022] Open
Abstract
Background To successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument. Methods The content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability. Results We developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICC’s range −0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICC’s range 0.0 to 0.82). Conclusions We developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument.
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Affiliation(s)
- Naomi E Cahill
- Department of Public Health Sciences, Queen's University, Carruthers Hall, Kingston, Ontario, Canada.
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Rahman A, Martin C, Heyland DK. Nutrition therapy for the critically ill surgical patient with aortic aneurysmal rupture: defining and improving current practice. JPEN J Parenter Enteral Nutr 2013; 39:104-13. [PMID: 23976774 DOI: 10.1177/0148607113501695] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Our goal is to define nutrition therapy in critically ill patients after surgical repair of acute ruptured or dissecting aortic aneurysm to identify opportunities for quality improvement. METHODS International, prospective studies in 2007-2009 and 2011 were combined. Sites provided institutional and patient characteristics including from intensive care units (ICUs) admission to ICU discharge for a maximum of 12 days. We selected patients with aortic aneurysmal rupture or acute dissection staying in the ICU for ≥ 3 days. RESULTS There were 104 eligible patients from 72 distinct ICUs analyzed. Overall, 86.5% received artificial nutrition. There were 50.0% patients who received enteral nutrition (EN) only, 29.8% patients received a combination of EN and parenteral nutrition (PN), 6.7% patients received PN only, and 13.5% did not receive any nutrition. The mean time from admission to initiation of EN was 3.0 days (SD ± 2.4 days). The adequacy of calories from nutrition support was 46.8% (range 0%-111%) with a mean of 10.0 kcal/kg/day. Of the total of 83 patients who received EN, 53 patients (63.8%) had interruption of EN. The reasons included fasting, intolerance, patients deemed too sick for enteral feeding, and loss of enteral feeding route. For patients with gastrointestinal intolerance, 3/30 patients (10%) received small bowel feeding and 23/30 patients (76.7%) of patients received motility agents. CONCLUSION Postoperative critically ill patients with aortic aneurysmal rupture or acute dissection are at high risk for inadequate nutrition therapy, and there may be inadequate utilization of strategies to improve nutrition uptake.
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Affiliation(s)
- Adam Rahman
- Department of Medicine, University of Western Ontario, London, Ontario, Canada St. Joseph's Healthcare Centre/London Health Sciences Centre, London, Ontario, Canada
| | - Claudio Martin
- Department of Medicine, University of Western Ontario, London, Ontario, Canada Critical Care/Trauma Centre, London Health Sciences Centre, Victoria Campus, London, Ontario, Canada Lawson Health Research Institute, London, Ontario, Canada
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Hoffer LJ, Bistrian BR. Why critically ill patients are protein deprived. JPEN J Parenter Enteral Nutr 2013; 37:300-9. [PMID: 23459750 DOI: 10.1177/0148607113478192] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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Hauschild TB, Fu KY, Hipwell RC, Baraghoshi G, Mone MC, Nirula R, Kimball EJ, Barton RG. Safe, timely, convenient, and cost-effective: a single-center experience with bedside placement of enteral feeding tubes by midlevel providers using fluoroscopic guidance. Am J Surg 2012; 204:958-62; discussion 962. [DOI: 10.1016/j.amjsurg.2012.07.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/11/2012] [Accepted: 07/02/2012] [Indexed: 01/30/2023]
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Friese RS. The open abdomen: definitions, management principles, and nutrition support considerations. Nutr Clin Pract 2012; 27:492-8. [PMID: 22714062 DOI: 10.1177/0884533612446197] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The use of the "open abdomen" as a technique in the management of the complex surgical patient stems from the concept of damage control. Damage control principles underscore the importance of an abbreviated laparotomy focused on control of hemorrhage and gastrointestinal contamination in patients presenting with significant physiologic compromise. Definitive repair of injuries is postponed and the abdomen is temporarily "closed" using one of a number of different techniques. The ultimate goal is formal abdominal fascial closure within 48-72 hours of the initial laparotomy. Frequently, daily trips to the operating room are required for incremental closure of the abdominal fascia. However, in some cases, fascial closure is not possible secondary to ongoing visceral edema and loss of the peritoneal domain. In these cases, the patient is left with an "open abdomen" until skin grafting over the exposed peritoneal organs can be performed. Patients with an open abdomen have peritoneal contents exposed to the atmosphere and require a complex dressing to maintain fascial domain and provide protection to exposed organs. These patients are typically critically ill and managed in the intensive care unit early in the disease process. The open abdomen has become an important tool for the management of physiologically unstable patients requiring emergent abdominal surgical procedures. These patients present unique challenges to the critical care and nutrition support teams. Careful attention to fluid and electrolyte management, meticulous wound care, prevention of enteroatmospheric fistula, and individualized nutrition support therapy are essential to successful recovery in this patient population.
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Affiliation(s)
- Randall S Friese
- University of Arizona, College of Medicine, Tucson, AZ 85727-5063, USA.
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Hurt RT, Frazier TH, McClave SA, Cave MC. Pharmaconutrition for the Obese, Critically Ill Patient. JPEN J Parenter Enteral Nutr 2011; 35:60S-72S. [DOI: 10.1177/0148607111413775] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Ryan T. Hurt
- Department of Medicine
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas H. Frazier
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Stephen A. McClave
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
| | - Matt C. Cave
- Department of Medicine
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky
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Nematy M, Mohajeri SAR, Moghadam SA, Safarian M, Norouzy A, Parizadeh SMR, Azarpazhooh MR, Siadat Z, Gharbi NS, Mobarhan MG. Nutritional status in intensive care unit patients: a prospective clinical cohort pilot study. MEDITERRANEAN JOURNAL OF NUTRITION AND METABOLISM 2011. [DOI: 10.1007/s12349-011-0071-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Drover JW, Cahill NE, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day AG, Heyland DK. Nutrition therapy for the critically ill surgical patient: we need to do better! JPEN J Parenter Enteral Nutr 2011; 34:644-52. [PMID: 21097764 DOI: 10.1177/0148607110372391] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. METHODS International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. RESULTS A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. CONCLUSIONS Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.
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Affiliation(s)
- John W Drover
- Department of Surgery, Queen'sUniversity, Kingston, Ontario, Canada
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Woo SH, Finch CK, Broyles JE, Wan J, Boswell R, Hurdle A. Early vs delayed enteral nutrition in critically ill medical patients. Nutr Clin Pract 2010; 25:205-11. [PMID: 20413702 DOI: 10.1177/0884533610361605] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study was conducted to identify current practice in provision of enteral nutrition (EN) and to determine effects of early enteral nutrition (EEN) on length of stay in the medical intensive care unit (ICU). In this prospective, observational study, medical ICU patients were evaluated to determine their candidacy for EEN. If patients were candidates for EN and expected to remain nothing-by-mouth for 48 hours, they were classified as receiving EEN (within 24 hours of admission) or delayed EN. Thirty-six patients were candidates for EEN. Eighteen received EEN and 18 received delayed EN. In the delayed group, the median time to start of EN was 2.1 +/- 4.8 days. Median ICU length of stay was 4.7 +/- 3.5 days in the EEN group compared with 8.5 +/- 8.3 days in the delayed group. Although hospital length of stay was shorter in the EEN group, this was not statistically significant (10.4 +/- 6.9 vs 16.9 +/- 11.5 days). Time on the ventilator was significantly shorter in the EEN group vs delayed (n = 30, 3.0 +/- 4.2 vs 6.0 +/- 9.2 days). The incidence of new pneumonia was lower in the EEN group (5.5% vs 44%), but no difference was found in the incidence of bacteremia. Hospital mortality was lower in the EEN group (1 vs 7 deaths). Given its association with numerous benefits, EEN within 24 hours of admission should be encouraged and implemented by clinicians in medical ICU patients, but additional research is needed.
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Thiamine supplementation increases serum thiamine and reduces pyruvate and lactate levels in burn patients. Burns 2010; 36:261-9. [DOI: 10.1016/j.burns.2009.04.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 03/16/2009] [Accepted: 04/11/2009] [Indexed: 11/22/2022]
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Hepatocellular integrity after parenteral nutrition: comparison of a fish-oil-containing lipid emulsion with an olive-soybean oil-based lipid emulsion. Eur J Anaesthesiol 2009; 26:1076-82. [DOI: 10.1097/eja.0b013e32832e08e0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Cheatham ML. Nonoperative management of intraabdominal hypertension and abdominal compartment syndrome. World J Surg 2009; 33:1116-22. [PMID: 19363690 DOI: 10.1007/s00268-009-0003-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have detrimental effects on all organ systems and are associated with significant morbidity and mortality. In recent years, the diagnosis and management of these syndromes has evolved tremendously, and the importance of comprehensive strategies to reduce intraabdominal pressure (IAP) has been recognized. All clinicians should be aware of the risk factors that predict the development of IAH/ACS, the appropriate measurement of IAP, and the current resuscitation options for managing these highly morbid syndromes. The nonoperative management of IAH/ACS can be summarized using five therapeutic goals: evacuate intraluminal contents, evacuate intraabdominal space-occupying lesions, improve abdominal wall compliance, optimize fluid administration, and optimize systemic and regional tissue perfusion. Surgical intervention through open abdominal decompression should immediately be pursued for patients with progressive IAH, end-organ dysfunction, and failure that is refractory to these nonoperative therapies. This comprehensive management strategy has been demonstrated to improve patient survival and long-term outcome.
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Affiliation(s)
- Michael L Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, 86 West Underwood Street, Suite 201, Orlando, FL 32806, USA.
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Joffe A, Anton N, Lequier L, Vandermeer B, Tjosvold L, Larsen B, Hartling L. Nutritional support for critically ill children. Cochrane Database Syst Rev 2009:CD005144. [PMID: 19370617 DOI: 10.1002/14651858.cd005144.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Nutritional support in the critically ill child has not been well investigated and is a controversial topic within paediatric intensive care. There are no clear guidelines as to the best form or timing of nutrition in critically ill infants and children. OBJECTIVES To assess the impact of enteral and total parenteral nutrition on clinically important outcomes for critically ill children. SEARCH STRATEGY We searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1); Ovid MEDLINE (1966 to February 2007); Ovid EMBASE (1988 to February 2007); OVID Evidence-Based Medicine Reviews; ISI Web of Science - Science Citation Index Expanded (1965 to February 2007); WebSPIRS Biological Abstracts (1969 to February 2007); and WebSPIRS CAB Abstracts (1972 to February 2007). We also searched trial registries; reviewed reference lists of all potentially relevant studies; handsearched relevant conference proceedings; and contacted experts in the area and manufacturers of enteral and parenteral nutrition products. We did not limit the search by language or publication status. SELECTION CRITERIA We included studies if they were randomized controlled trials; involved paediatric patients, aged one day to 18 years of age, cared for in a paediatric intensive care unit setting (PICU) and received nutrition within the first seven days of admission; and reported data for at least one of the pre-specified outcomes (30-day or PICU mortality; length of stay in PICU or hospital; number of ventilator days; and morbid complications, such as nosocomial infections). We excluded studies if they only reported nutritional outcomes, quality of life assessments, or economic implications. Furthermore, other areas of paediatric nutrition, such as immunonutrition and different routes of delivering enteral nutrition, were not addressed in this review. DATA COLLECTION AND ANALYSIS Two authors independently screened searches, applied inclusion criteria, and performed quality assessments. We resolved discrepancies through discussion and consensus. One author extracted data and a second checked data for accuracy and completeness. MAIN RESULTS Only one trial was identified as relevant. Seventy-seven children in intensive care with burns involving > 25% of the total body surface area were randomized to either enteral nutrition within 24 hours or after at least 48 hours. No statistically significant differences were observed for mortality, sepsis, ventilator days, length of stay, unexpected adverse events, resting energy expenditure, nitrogen balance, or albumin levels. The trial was assessed as of low methodological quality (based on the Jadad scale) with an unclear risk of bias. AUTHORS' CONCLUSIONS There was only one randomized trial relevant to the review question. Research is urgently needed to identify best practices regarding the timing and forms of nutrition for critically ill infants and children.
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Affiliation(s)
- Ari Joffe
- Department of Pediatrics, Division of Pediatric Intensive Care, University of Alberta and Stollery Children's Hospital, Office 3A3.07, 8440- 112 St, Edmonton, Alberta, Canada, T6G 2B7.
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Rauch S, Krueger K, Turan A, Roewer N, Sessler DI. Determining small intestinal transit time and pathomorphology in critically ill patients using video capsule technology. Intensive Care Med 2009; 35:1054-9. [DOI: 10.1007/s00134-009-1415-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 12/11/2008] [Indexed: 12/22/2022]
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Cerezo Ruiz A, Naranjo Rodríguez A, Hervás Molina AJ, Casais Juanena L, García Sánchez MV, Gálvez Calderón C, González Galilea A, de Dios Vega JF. [Usefulness of ultrathin transnasal endoscopy for the placement of nasoenteric feeding tubes]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:633-6. [PMID: 19174079 DOI: 10.1016/s0210-5705(08)75810-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 05/15/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Placement of nasoenteral feeding tubes can require endoscopic support. AIM To analyze the usefulness of transnasal ultrathin endoscopy in the placement of nasoenteral feeding tubes. PATIENTS AND METHODS We performed an ambispective study of all patients who underwent nasoenteral feeding (4.9 mm) in 2007. RESULTS Twenty-six procedures were performed. The mean age of the patients was 69.3+/-13 years. Nasal anesthesia was used in 23 patients (88.4%), and midazolam in 8 (30.8%). No anesthesia was used in 4 patients (15.3%). INDICATIONS stenotic esophageal lesions (42.3%), distal placement to the pathological alteration (46.1%), and failure of placement through the normal route (11.5%). We placed 13 (50%) nasoduodenal, 7 (29.6%) nasogastric and 6 (23.1%) nasojejunal tubes. The success rate was 100%. The most frequently used calibre was 12 F. There were no complications. CONCLUSIONS The use of transnasal ultrathin endoscopy in the placement of nasoenteral feeding tubes in our patients was safe, effective and relatively easy.
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Affiliation(s)
- Antonio Cerezo Ruiz
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Reina Sofía, Córdoba, Spain.
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Bryk J, Ochoa JB, Correia MIT, Munera-Seeley V, Popovic PJ. Effect of citrulline and glutamine on nitric oxide production in RAW 264.7 cells in an arginine-depleted environment. JPEN J Parenter Enteral Nutr 2008; 32:377-83. [PMID: 18596308 DOI: 10.1177/0148607108319807] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Nitric oxide (NO) is a highly reactive free radical essential for antimicrobial and tumor immunity as well as endothelial function. Arginine is a limiting factor in NO synthesis. Citrulline can be converted to arginine and might restore NO production when arginine availability is limited, while glutamine may competitively inhibit citrulline availability. We aimed to assess how these amino acids interact to generate NO using an in vitro model. METHODS RAW 264.7 cells were exposed to various amino acid concentrations before and after lipopolysaccharide (LPS) stimulation, and NO production was assessed. RESULTS NO production directly correlated up to 200 microM with arginine available after LPS stimulation (R(2) = 0.99). Provided the same arginine concentrations following LPS stimulation, low arginine precultured cells produced significantly less NO than high arginine precultured cells (P < .01). Citrulline added to low arginine preculture significantly increased NO production compared to cells in low arginine alone (P < .01). When glutamine was withdrawn before and after LPS stimulation, cells precultured in low arginine and citrulline produced NO equivalent to that of high arginine precultured cells. Additional citrulline provided after LPS stimulation additionally improved NO production beyond that observed in cells precultured in high arginine (P < .01), and NO production became less dependent on arginine availability (R(2) = 0.78). CONCLUSION Arginine availability is a limiting factor for NO production. Citrulline is a potential substitute to restore NO production when arginine availability is limited. Glutamine appears to be an important modulator that interferes with citrulline-mediated NO production.
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Affiliation(s)
- Jodie Bryk
- School of Medicine, University of Pittsburgh Medical School, Pittsburgh, PA 15213, USA
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Behara AS, Peterson SJ, Chen Y, Butsch J, Lateef O, Komanduri S. Nutrition support in the critically ill: a physician survey. JPEN J Parenter Enteral Nutr 2008; 32:113-9. [PMID: 18407903 DOI: 10.1177/0148607108314763] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. METHODS The authors electronically distributed a 12-question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. RESULTS On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty-two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. CONCLUSIONS This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition-related education at all levels of training.
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Affiliation(s)
- Ami Shah Behara
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois 60612, USA
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Initiation of nutrition in the intensive care unit and the reasons for its delay: a prospective audit. Proc Nutr Soc 2008. [DOI: 10.1017/s0029665108007830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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de Aguilar-Nascimento JE, Kudsk KA. Early nutritional therapy: the role of enteral and parenteral routes. Curr Opin Clin Nutr Metab Care 2008; 11:255-60. [PMID: 18403921 DOI: 10.1097/mco.0b013e3282fba5c6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. RECENT FINDINGS Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. SUMMARY Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.
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Initiation of nutrition in the intensive care unit and the reasons for
its delay: a prospective audit. Proc Nutr Soc 2008. [DOI: 10.1017/s0029665100591368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Windle EM. Nutrition support in major burn injury: case analysis of dietetic activity, resource use and cost implications. J Hum Nutr Diet 2008; 21:165-73; quiz 174-6. [DOI: 10.1111/j.1365-277x.2008.00860.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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O’Meara D, Mireles-Cabodevila E, Frame F, Hummell AC, Hammel J, Dweik RA, Arroliga AC. Evaluation of Delivery of Enteral Nutrition in Critically Ill Patients Receiving Mechanical Ventilation. Am J Crit Care 2008. [DOI: 10.4037/ajcc2008.17.1.53] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Published reports consistently describe incomplete delivery of prescribed enteral nutrition. Which specific step in the process delays or interferes with the administration of a full dose of nutrients is unclear.
Objectives To assess factors associated with interruptions in enteral nutrition in critically ill patients receiving mechanical ventilation.
Methods An observational prospective study of 59 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an 18-bed medical intensive care unit of an academic center. Data were collected prospectively on standardized forms. Steps involved in the feeding process from admission to discharge were recorded, each step was timed, and delivery of nutrition was quantified.
Results Patients received approximately 50% (mean, 1106.3; SD, 885.9 Cal) of the prescribed caloric needs. Enteral nutrition was interrupted 27.3% of the available time. A mean of 1.13 interruptions occurred per patient per day; enteral nutrition was interrupted a mean of 6 (SD, 0.9) hours per patient each day. Prolonged interruptions were mainly associated with problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%), weaning (11.7%), and other reasons (22.8%). Placement and confirmation of placement of the small-bore feeding tube were significant causes of incomplete delivery of nutrients on the day of admission.
Conclusions Delivery of enteral nutrition in critically ill patients receiving mechanical ventilation is interrupted by practices embedded in the care of these patients. Evaluation of the process reveals areas to improve the delivery of enteral nutrition.
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Affiliation(s)
- Debra O’Meara
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Eduardo Mireles-Cabodevila
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Fran Frame
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - A. Christine Hummell
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jeffrey Hammel
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Raed A. Dweik
- Debra O’Meara and Fran Frame are registered nurses in the Department of Nursing; Eduardo Mireles-Cabodevila and Raed A. Dweik are physicians in the Department of Pulmonary, Allergy, and Critical Care Medicine; A. Christine Hummell is a registered dietitian in the Department of Nutritional Therapy; and Jeffrey Hammel is a biostatistician in the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Alejandro C. Arroliga
- Alejandro C. Arroliga is the director of the Department of Pulmonary and Critical Care Medicine at Scott and White Hospital and professor of medicine at Texas A&M College of Medicine in Temple, Texas
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48
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Zanotti-Cavazzoni SL, Dellinger RP, Parrillo JE. Severe Sepsis and Multiple Organ Dysfunction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50028-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jones NE, Dhaliwal R, Day AG, Ouellette-Kuntz H, Heyland DK. Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Crit Care 2007; 23:301-7. [PMID: 18725033 DOI: 10.1016/j.jcrc.2007.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 07/23/2007] [Accepted: 08/13/2007] [Indexed: 01/15/2023]
Abstract
PURPOSE The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs). MATERIALS AND METHODS We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN / energy prescribed by the dietitian x 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy. RESULTS The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs. CONCLUSIONS Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.
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Affiliation(s)
- Naomi E Jones
- Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada
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50
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Herbert MK, Holzer P. Standardized concept for the treatment of gastrointestinal dysmotility in critically ill patients--current status and future options. Clin Nutr 2007; 27:25-41. [PMID: 17933437 DOI: 10.1016/j.clnu.2007.08.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Accepted: 07/20/2007] [Indexed: 12/22/2022]
Abstract
Inhibition of gastrointestinal motility is a major problem in critically ill patients. Motor stasis gives rise to subsequent complications including intolerance to enteral feeding, enhanced permeability of the atrophic intestinal mucosa and conditions as severe as systemic inflammatory response syndrome, sepsis and multiple organ failure. Although the diagnosis of motility disturbances in critically ill patients is difficult, the type and site of the disturbance are important to consider in the analysis of the condition and in the choice of therapeutic approach. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle for the clinician, because the underlying mechanisms are complex and not fully understood and the availability of pharmacological treatment options is limited. In addition, there is a lack of controlled studies on which to build an evidence-based treatment concept for critically ill patients. Notwithstanding this situation, there has been remarkable progress in the understanding of the integrated regulation of gastrointestinal motility in health and disease. These advances, which largely relate to the organization of the enteric nervous system and its signaling mechanisms, enable the intensivist to develop a standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients.
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Affiliation(s)
- Michael K Herbert
- Department of Anaesthesiology, University of Wuerzburg, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany.
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