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Slingerland-Boot R, Kummerow M, Arbous SM, van Zanten ARH. Association between first-week propofol administration and long-term outcomes of critically ill mechanically ventilated patients: A retrospective cohort study. Clin Nutr 2024; 43:42-51. [PMID: 38000194 DOI: 10.1016/j.clnu.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/21/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND & AIM Propofol is commonly used in ICUs, but its long-term effects have not been thoroughly studied. In vitro studies suggest it may harm mitochondrial function, potentially affecting clinical outcomes. This study aimed to investigate the association between substantial propofol sedation and clinical outcomes in critically ill patients. METHODS We conducted a single-centre cohort study of critically ill, mechanically ventilated (≥7 days) adults to compare patients who received a substantial dose of propofol (cumulative >500 mg) during the first week of ICU admission with those who did not. The primary outcome was the association between substantial propofol administration and 6-month mortality, adjusted for relevant covariates. Subanalyses were performed for administration in the early (day 1-3) and late (day 4-7) acute phases of critical illness due to the metabolic changes in this period. Secondary outcomes included tracheostomy need and duration, length of ICU and hospital stay (LOS), discharge destinations, ICU, hospital, and 3-month mortality. RESULTS A total of 839 patients were enrolled, with 73.7 % receiving substantial propofol administration (substantial propofol dose group). Six-month all-cause mortality was 32.4 %. After adjusting for relevant variables, we found no statistically significant difference in 6-month mortality between both groups. There were also no significant differences in secondary outcomes. CONCLUSION Our study suggests that substantial propofol administration during the first week of ICU stay in the least sick critically ill, mechanically ventilated adult patients is safe, with no significant associations found with 6-month mortality, ICU or hospital LOS, differences in discharge destinations or need for tracheostomy.
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Affiliation(s)
- Rianne Slingerland-Boot
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands
| | - Maren Kummerow
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands
| | - Sesmu M Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
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2
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Nesvadba D, Sime N, Jansen J. Measurement of the calorific content of propofol using bomb calorimetry. J Intensive Care Soc 2023; 24:27-28. [PMID: 37928073 PMCID: PMC10621515 DOI: 10.1177/1751143720940686] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
- David Nesvadba
- Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Nicole Sime
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen UK
| | - Jan Jansen
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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3
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Singer P, Blaser AR, Berger MM, Calder PC, Casaer M, Hiesmayr M, Mayer K, Montejo-Gonzalez JC, Pichard C, Preiser JC, Szczeklik W, van Zanten ARH, Bischoff SC. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2023; 42:1671-1689. [PMID: 37517372 DOI: 10.1016/j.clnu.2023.07.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
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Affiliation(s)
- Pierre Singer
- Intensive Care Unit, Herzlia Medical Center and Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, and Intensive Care Unit, Herzlia Medical Center, Israel.
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Mette M Berger
- Faculty of Biology and Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Catholic University Hospitals (UZLeuven) and Catholic University Leuven, Leuven, Belgium
| | - Michael Hiesmayr
- Division Cardiac-, Thoracic-, Vascular Anaesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Konstantin Mayer
- Department of Pneumonology, Infectious Diseases and Sleep Medicine, St. Vincentius Kliniken gAG, Karlsruhe, Germany
| | | | - Claude Pichard
- Department of Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Charles Preiser
- Medical Direction, Hopital Universitaire de Bruxelles, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College & Anesthesia and Intensive Care Department, 5th Military Hospital, Krakow, Poland
| | - Arthur R H van Zanten
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands & Wageningen University & Research, Wageningen, the Netherlands
| | - Stephan C Bischoff
- Department of Nutritional Medicine/Prevention, University of Hohenheim, Stuttgart, Germany
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4
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Kasti AN, Theodorakopoulou M, Katsas K, Synodinou KD, Nikolaki MD, Zouridaki AE, Fotiou S, Kapetani A, Armaganidis A. Factors Associated with Interruptions of Enteral Nutrition and the Impact on Macro- and Micronutrient Deficits in ICU Patients. Nutrients 2023; 15:nu15040917. [PMID: 36839275 PMCID: PMC9959226 DOI: 10.3390/nu15040917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND AND AIM Feeding interruptions in critical care patients are often unjustified. We aimed to determine the causes, duration, and frequency of enteral nutrition interruptions (ENIs) and to assess macronutrients and antioxidant deficits according to European Society of Parenteral Enteral Nutrition (ESPEN) guidelines. METHODS We prospectively enrolled Intensive Care Unit (ICU) patients admitted for more than 48 h with an inability to orally eat from April to December 2019. The type of enteral nutrition, the number of calories administered, the time of feeding initiation, the reasons for delaying feeding, and the causes for ENI were recorded. RESULTS 81 patients were enrolled, with a median duration of ENIs of 5.2 (3.4-7.4) hours/day. Gastric residual volume (GRV) monitoring-a highly controversial practice-was the most common cause of ENI (median duration 3 (2.3-3) hours/day). The mean energy intake was 1037 ± 281 kcal/day, while 60.5% of patients covered less than 65% of the total energy needs (1751 ± 295 kcal/day, according to mean Body Mass Index (BMI)). The median daily protein intake did not exceed 0.43 ± 0.3 gr/kg/day of the actual body weight (BW), whereas ESPEN recommends 1.3 gr/kg/day for adjusted BW (p < 0.001). The average administration of micronutrients and antioxidants (arginine, selenium, zinc, vitamins) was significantly less than the dietary reference intake (p < 0.01). CONCLUSION ENIs lead to substantial caloric, protein, and antioxidant deficits.
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Affiliation(s)
- Arezina N. Kasti
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Maria Theodorakopoulou
- 1st ICU Department, Evangelismos Hospital, Intensive Care Medicine, 10676 Athens, Greece
- 2nd ICU Department, Attikon University Hospital, Intensive Care Medicine, 12461 Athens, Greece
| | - Konstantinos Katsas
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Kalliopi D. Synodinou
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Maroulla D. Nikolaki
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
- Department of Nutrition and Dietetics Sciences, Hellenic Mediterranean University, 72300 Crete, Greece
- Correspondence: (M.D.N.); (A.A.)
| | - Alice Efstathia Zouridaki
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
- Department of Human Biology and Health Studies, University of Toronto, Toronto, ON M5S, Canada
| | - Stylianos Fotiou
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 17676 Athens, Greece
| | - Aliki Kapetani
- Department of Nutrition and Dietetics, Attikon University General Hospital, 12462 Athens, Greece
| | - Apostolos Armaganidis
- 2nd ICU Department, Attikon University Hospital, Intensive Care Medicine, 12461 Athens, Greece
- Correspondence: (M.D.N.); (A.A.)
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Le Cam E, Pardo E. Délai d’introduction de la nutrition parentérale en réanimation : nouvelles données de la littérature. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Wechselberger S, Compton F, Schilling J. Impact of Continuous Veno-Venous HemoDiALYsis with Regional Citrate Anticoagulation on Non-NUTRItional Calorie Balance in Patients on the ICU-The NUTRI-DAY Study. Nutrients 2022; 15:nu15010063. [PMID: 36615721 PMCID: PMC9824471 DOI: 10.3390/nu15010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Malnutrition as well as overfeeding can have negative impacts on clinical outcomes in critically ill patients. Continuous veno-venous hemodialysis (CVVHD) with regional citrate anticoagulation (RCA) using trisodium citrate 4% (TSC) might play a role in nutrient disposition in patients in the ICU. Methods: In 33 consecutive patients on CVVHD with RCA, energy uptake or loss was calculated. Three macronutrients (lactate, glucose and citrate) were analyzed by taking prefilter blood and effluent samples. Results: Glucose and lactate clearance through CVVHD made up for a loss of 61 kcal/d (IQR 25−164 kcal/d) and 38 kcal/d (IQR 23−59 kcal/d), respectively. Two patients with hyperglycemic state (>350 mg/dL) lost around 600 kcal/d during CVVHD. Net post-filter citrate caloric delivery through RCA was 135 kcal/d (IQR: 124−144 kcal/d). Adding the three macronutrients, net caloric gain through CVVHD was 10 kcal/d (IQR: −63−75 kcal/d). Conclusion: In non-hyperglycemic patients on CVVHD with RCA, the metabolic contribution of the three macronutrients lactate, glucose and citrate is neglectable.
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Alves de Paula J, Rabito EI, Justino SR, Leite LS, Dantas D, Makiyama da Silva JS, Maffini LF, Júnior OR. Administration of enteral nutrition and gastrointestinal complications in Covid-19 critical patients in prone position. CLINICAL NUTRITION OPEN SCIENCE 2022; 45:80-90. [PMID: 36059438 PMCID: PMC9420200 DOI: 10.1016/j.nutos.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/20/2022] [Indexed: 12/15/2022] Open
Abstract
Background The prone position (PP) used in the treatment of critically ill patients infected with SARS-CoV-2, may be a barrier to enteral nutrition (EN). This study aimed to analyze the effectiveness and complications of EN in the PP, as well as clinical outcomes. Methods Prospective cohort study with patients in EN and coronavirus disease 2019 (COVID-19), on mechanical ventilation (MV), which whom needed or not PP. Gastrointestinal intolerances (GII) related to PP were evaluated, and correlated with possible confounding factors. EN, days on MV, Intensive Care Unit (ICU) length of stay, hospital length of stay, ventilator-associated pneumonia (VAP) and mortality were analyzed. The data were evaluated daily and compared prone group (PG=57) and supine group (SG=69). Results The PP was associated with GII (P=0.000) and presented in 32 patients (26,44%) with no difference among groups. Association between epinephrine (P=0.003), vasopressin (P=0.018), and GII was observed. There was no difference between the total volume of enteral nutrition (TVEN) infused in the groups. However, the mean EN infused for the days when the patient was on PP was (70.0% ± 31.5) and for the days in supine position was (74.8% ± 27.3), P= 0.006. The PG had a longer time on MV (P=0.005) and ICU (P=0.003) and PP was associated with VAP (P=<0.001). The infused TVEN showed no association with VAP (P=0.09). Conclusion PP was a determining factor in GII and proved to be a risk factor for VAP, but the EN protocol seems to have ensured an adequate EN supply in PP and be a safe alternative.
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Affiliation(s)
- Jéssica Alves de Paula
- Clinical Nutrition Unit, Clinical Hospital Complex - Federal University of Paraná, Curitiba-PR, Brazil
| | | | - Sandra Regina Justino
- Nutrition Department of the Brazilian Association of Intensive Care Medicine, São Paulo-SP, Brazil
- Nutrition Department of the Intensive Care Society of Paraná Brazil, Curitiba-PR, Brazil
| | - Luíza Silva Leite
- Clinical Nutrition Unit, Clinical Hospital Complex - Federal University of Paraná, Curitiba-PR, Brazil
| | - Danielle Dantas
- Clinical Nutrition Unit, Clinical Hospital Complex - Federal University of Paraná, Curitiba-PR, Brazil
| | | | - Larissa Farinha Maffini
- Clinical Nutrition Unit, Clinical Hospital Complex - Federal University of Paraná, Curitiba-PR, Brazil
| | - Odery Ramos Júnior
- Department of Internal Medicine, Gastroenterology Division, Clinical Hospital Complex - Federal University of Paraná, Curitiba-PR, Brazil
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8
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Li P, Huang Y, Wong A. An analysis of non-nutritive calories from propofol, dextrose, and citrate among critically ill patients receiving continuous renal replacement therapy. JPEN J Parenter Enteral Nutr 2022; 46:1883-1891. [PMID: 35589384 DOI: 10.1002/jpen.2405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Propofol, dextrose, and citrate infusions are necessary treatment modalities in the intensive care units (ICUs). They are, however, a potential source of non-nutritive calories (NNCs) which may cause over-feeding and adverse complications. The literature surrounding the role of NNCs is limited. We aimed to examine the energy contribution of NNCs. Our secondary aim is to assess the nutritional impact of NNCs, especially among patients receiving continuous renal replacement therapy (CRRT). MATERIALS /METHODS We enrolled 177 mechanically ventilated patients admitted to medical-surgical ICUs from August to December 2019. Patients were monitored over the first 7 days of admission. Infusion rates of EN/PN and NNCs, as well as clinical characteristics, were examined. Patients receiving CRRT were compared to those without. RESULTS In total, 24% received additional energy from citrate. Patients received a maximum of 331kcal from citrate, 492kcal from propofol, and 992kcal from dextrose per ICU day. CRRT-group achieved higher total energy on the first two days (Day 1 - 55.1% vs. 46.4%; p=0.008, Day 2 - 73.2% vs. 55.4%, p=0.025). They also received higher mean NNCs on all days, except for Day 1 (p=0.068). CONCLUSION NNCs, especially citrate, are significant sources of energy. Patients receiving CRRT may have greater nutritional risk. There should be close monitoring and adaption of energy prescription accordingly to prevent over-feeding. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Priscilla Li
- Department of Dietetics and Food Services, Changi General Hospital, Singapore
| | - Yingxiao Huang
- Department of Dietetics and Food Services, Changi General Hospital, Singapore
| | - Alvin Wong
- Department of Dietetics and Food Services, Changi General Hospital, Singapore
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9
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de Sequera P, Pérez-García R, Molina M, Álvarez-Fernández G, Muñoz-González RI, Mérida E, Camba MJ, Blázquez LA, Alcaide MP, Echarri R. Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study. Nefrologia 2022; 42:327-337. [PMID: 36210622 DOI: 10.1016/j.nefroe.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 06/16/2023] Open
Abstract
Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work we described the acute changes during an HD session with a DF with citrate instead of acetate. Now we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3 mmol/L acetate and 16 weeks with 1 mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, preHD ionic calcium and magnesium were significantly lower and PTH higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96 ± 2.33 kg/m2 when patients switched from LD with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.
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Affiliation(s)
- Patricia de Sequera
- Departamento de Medicina, Universidad Complutense, Madrid, Spain; Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain.
| | - Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Manuel Molina
- Servicio de Nefrología, Hospital Universitario General de Santa Lucía, Cartagena, Spain
| | | | | | - Evangelina Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Jesús Camba
- Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Orense, Spain
| | - Luis Alberto Blázquez
- Servicio de Nefrología, Hospital General Universitario de Guadalajara, Guadalajara, Spain
| | - Maria Paz Alcaide
- Servicio de Nefrología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rocío Echarri
- Servicio de Nefrología, Hospital Universitario Infanta Sofia, Madrid, Spain
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10
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Hill A, Elke G, Weimann A. Nutrition in the Intensive Care Unit-A Narrative Review. Nutrients 2021; 13:nu13082851. [PMID: 34445010 PMCID: PMC8400249 DOI: 10.3390/nu13082851] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, D-52074 Aachen, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Surgical Intensive Care Unit, Klinikum St. Georg, D-04129 Leipzig, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
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11
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de Sequera P, Pérez-García R, Molina M, Álvarez-Fernández G, Muñoz-González RI, Mérida E, Camba MJ, Blázquez LA, Alcaide MP, Echarri R. Advantages of the use of citrate over acetate as a stabilizer in hemodialysis fluid: A randomized ABC-treat study. Nefrologia 2021; 42:S0211-6995(21)00137-5. [PMID: 34391608 DOI: 10.1016/j.nefro.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022] Open
Abstract
Hemodialysis (HD) with bicarbonate dialysis fluid (DF) requires the presence of an acid to prevent the precipitation of calcium and magnesium carbonate. The most used acid is acetic acid, with it several complications have been described. In a previous work, we described the acute changes during an HD session with a DF with citrate instead of acetate. Now, we report the results in the medium term, 16 weeks. It is a prospective, multicenter, crossover and randomized study, where 56 HD patients with bicarbonate three times a week were dialysed for 16 weeks with 3mmol/L acetate and 16 weeks with 1mmol/L citrate. Patients older than 18 years with a previous stay on HD of more than 3 months and with a normal functioning arteriovenous fistula were included. Epidemiological data, dialysis, bioimpedance, biochemistry before and after HD, as well as hypotensive episodes, were collected monthly. After 16 weeks of citrate treatment, pre-HD ionic calcium and magnesium were significantly lower and paratiroid hormone (PTH) higher than in the acetate period. No differences were observed in the effectiveness of dialysis. Hypotensive episodes were significantly more frequent with acetate than with citrate: 311 (14.1%) vs 238 (10.8%) sessions. The lean mass index increased by 0.96±2.33kg/m2 when patients switched from DF with acetate to citrate. HD with citrate modifies several parameters of bone mineral metabolism, not only acutely as previously described, but also in the long-term. The substitution of acetate for citrate improves hemodynamic stability, producing less hypotension and can improve nutritional status.
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Affiliation(s)
- Patricia de Sequera
- Departamento de Medicina, Universidad Complutense, Madrid, España; Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España.
| | - Rafael Pérez-García
- Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, España
| | - Manuel Molina
- Servicio de Nefrología, Hospital Universitario General de Santa Lucía, Cartagena, España
| | | | | | - Evangelina Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Maria Jesús Camba
- Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Orense, España
| | - Luis Alberto Blázquez
- Servicio de Nefrología, Hospital General Universitario de Guadalajara, Guadalajara, España
| | - María Paz Alcaide
- Servicio de Nefrología, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - Rocío Echarri
- Servicio de Nefrología, Hospital Universitario Infanta Sofia, Madrid, España
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12
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Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support. PHARMACY 2021; 9:pharmacy9030121. [PMID: 34287346 PMCID: PMC8293440 DOI: 10.3390/pharmacy9030121] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/16/2021] [Accepted: 06/25/2021] [Indexed: 11/17/2022] Open
Abstract
Propofol, a commonly used sedative in the intensive care unit, is formulated in a 10% lipid emulsion that contributes 1.1 kcals per mL. As a result, propofol can significantly contribute to caloric intake and can potentially result in complications of overfeeding for patients who receive concurrent enteral or parenteral nutrition therapy. In order to avoid potential overfeeding, some clinicians have empirically decreased the infusion rate of the nutrition therapy, which also may have detrimental effects since protein intake may be inadequate. The purpose of this review is to examine the current literature regarding these issues and provide some practical suggestions on how to restrict caloric intake to avoid overfeeding and simultaneously enhance protein intake for patients who receive either parenteral or enteral nutrition for those patients receiving concurrent propofol therapy.
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13
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Wierdsma NJ, Kruizenga HM, Konings LA, Krebbers D, Jorissen JR, Joosten MHI, van Aken LH, Tan FM, van Bodegraven AA, Soeters MR, Weijs PJ. Poor nutritional status, risk of sarcopenia and nutrition related complaints are prevalent in COVID-19 patients during and after hospital admission. Clin Nutr ESPEN 2021; 43:369-376. [PMID: 34024542 PMCID: PMC8056328 DOI: 10.1016/j.clnesp.2021.03.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Patients with COVID-19 infection presents with a broad clinical spectrum of symptoms and complications. As a consequence nutritional requirements are not met, resulting in weight- and muscle loss, and malnutrition. The aim of the present study is to delineate nutritional complaints, the (course of the) nutritional status and risk of sarcopenia of COVID-19 patients, during hospitalisation and after discharge. METHODS In this prospective observational study in 407 hospital admitted COVID-19 patients in four university and peripheral hospitals, data were collected during dietetic consultations. Presence of nutrition related complaints (decreased appetite, loss of smell, changed taste, loss of taste, chewing and swallowing problems, nausea, vomiting, feeling of being full, stool frequency and consistency, gastric retention, need for help with food intake due to weakness and shortness of breath and nutritional status (weight loss, BMI, risk of sarcopenia with SARC-F ≥4 points) before, during hospital stay and after discharge were, where possible, collected. RESULTS Included patients were most men (69%), median age of 64.8 ± 12.4 years, 60% were admitted to ICU at any time point during hospitalisation with a median LOS of 15 days and an in-hospital mortality rate of 21%. The most commonly reported complaints were: decreased appetite (58%), feeling of being full (49%) and shortness of breath (43%). One in three patients experienced changed taste, loss of taste and/or loss of smell. Prior to hospital admission, 67% of the patients was overweight (BMI >25 kg/m2), 35% of the patients was characterised as malnourished, mainly caused by considerable weight loss. Serious acute weight loss (>5 kg) was showed in 22% of the patents during the hospital stay; most of these patients (85%) were admitted to the ICU at any point in time. A high risk of sarcopenia (SARC-F ≥ 4 points) was scored in 73% of the patients during hospital admission. CONCLUSION In conclusion, one in five hospital admitted COVID-19 patients suffered from serious acute weight loss and 73% had a high risk of sarcopenia. Moreover, almost all patients had one or more nutritional complaints. Of these complaints, decreased appetite, feeling of being full, shortness of breath and changed taste and loss of taste were the most predominant nutrition related complaints. These symptoms have serious repercussions on nutritional status. Although nutritional complaints persisted a long time after discharge, only a small group of patients received dietetic treatment after hospital discharge in recovery phase. Clinicians should consider the risks of acute malnutrition and sarcopenia in COVID-19 patients and investigate multidisciplinary treatment including dietetics during hospital stay and after discharge.
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Affiliation(s)
- Nicolette J Wierdsma
- Department of Nutrition & Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Hinke M Kruizenga
- Department of Nutrition & Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Lotte Aml Konings
- Wageningen University and Research Center, Wageningen, the Netherlands.
| | - Daphne Krebbers
- Department of Dietetics, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands.
| | - Jolein Rmc Jorissen
- Department of Dietetics, Zuyderland Medical Center, Heerlen, Sittard-Geleen, the Netherlands.
| | - Marie-Helene I Joosten
- Department of Dietetics, Zuyderland Medical Center, Heerlen, Sittard-Geleen, the Netherlands.
| | - Loes H van Aken
- Department of Nutrition & Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Flora M Tan
- Department of Nutrition & Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Ad A van Bodegraven
- Department of Gastroenterology, Zuyderland Medical Center, Heerlen, Sittard-Geleen, the Netherlands.
| | - Maarten R Soeters
- Department of Endocrinology & Metabolism, Internal Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Peter Jm Weijs
- Department of Nutrition & Dietetics, Amsterdam University Medical Centers, AMS Research Institute, VU University, Amsterdam, the Netherlands.
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Osuna-Padilla I, Rodríguez-Moguel NC, Aguilar-Vargas A, Rodríguez-Llamazares S. Safety and tolerance of enteral nutrition in COVID-19 critically ill patients, a retrospective study. Clin Nutr ESPEN 2021; 43:495-500. [PMID: 34024561 PMCID: PMC7901378 DOI: 10.1016/j.clnesp.2021.02.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a lack of evidence about the tolerance of enteral nutrition (EN) in COVID-19 critically ill patients. However, several gastrointestinal manifestations related to COVID-19 have been described. The aims of this study were to analyze the incidence of gastrointestinal intolerance (GI) associated to EN (diarrhea, vomiting, gastroparesis and constipation) and to describe energy/protein provision along with biochemical alterations during the first week of EN. METHODS A retrospective cohort of COVID-19 critically ill patients under mechanical ventilation. We reported daily enteral nutrition infusion and gastrointestinal manifestations within the first week of intubation and enteral nutrition initiation. RESULTS Fifty-two patients were included; 40.3% were overweight and 46.2% were obese. During the first 7 days of EN, manifestations of GI intolerance such as vomiting, diarrhea and gastroparesis were present in 18 patients (32.4%). Hypernatremia (39%) was the most frequent electrolyte abnormality. Only Acute Kidney Injury (AKI) diagnosis was associated with a higher energy deficit on day 7. No associations between drug prescription and GI intolerance were observed. On day 4, 94.5% of patients were receiving more than 80% of energy requirements and 94.2% of protein requirements. Accumulated energy and protein deficits at day 3 were 2171.2 ± 945 kcal and 114.9 ± 49.2 g, respectively; and 2586.4 ± 1151 kcal, 133.3 ± 60.4 g at day 7. CONCLUSION Enteral nutrition is feasible and well-tolerated in COVID-19 patients with mechanical ventilation within the first week of enteral nutrition initiation. More studies are needed to elucidate the impact of nutritional therapy on infection course and outcomes.
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Affiliation(s)
- Iván Osuna-Padilla
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, Mexico
| | | | - Adriana Aguilar-Vargas
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, Mexico.
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15
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Singer P, De Waele E, Sanchez C, Ruiz Santana S, Montejo JC, Laterre PF, Soroksky A, Moscovici E, Kagan I. TICACOS international: A multi-center, randomized, prospective controlled study comparing tight calorie control versus Liberal calorie administration study. Clin Nutr 2021; 40:380-387. [PMID: 32534949 DOI: 10.1016/j.clnu.2020.05.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 01/25/2023]
Abstract
Since the first TICACOS study, 3 additional studies have been published comparing a medical nutrition therapy guided by indirect calorimetry to a regimen prescribed on the basis of predictive equations. A recent guidelines document included a meta-analysis including these 4 papers and found a trend for improvement (OR 0.98-1.48) in favor of medical nutrition therapy guided by indirect calorimetry in terms of survival. The aim of our study was to perform a multicenter prospective, randomized, controlled non blinded study in critically patients to assess the added value for measuring daily resting energy expenditure as a guide for nutritional support. The primary objective was to decrease infectious rate of these critically ill patients. MATERIAL AND METHODS This phase III, multi-center, randomized, controlled non blinded study was planned to include 580 newly-admitted, adult ventilated ICU patients that were planned to stay more than 48 h in the ICU departments. The nutritional support was aimed to meet 80-100% of energy requirement measured by indirect calorimetry. The calorie needs were determined by IC in the Study group and by an equation (20-25 kcal/kg ideal body weight/day) in the Control Group. The ICU staff was trained to strive to supply 80-100% of a patient's energy requirements through artificial nutrition, preferably enteral feeding. Primary endpoint was infection rate and secondary endpoints included other morbidities and mortality during ICU, at 90 and 180 days. Comparison between the study and the control group was performed using T test for equality of means (independent samples test). Correlations were performed using the Pearson correlation test. A p level of 0.05 or below was considered as significant. Cross tabs procedure used Chi-square test for testing differences in complication rates, length of stay and length of ventilation. Correlations between energy balances and complications was also be tested using one way analysis as well as ANOVA analysis between groups and within groups. Kaplan Meir curves assessed the proportion of surviving patients in the 2 groups. RESULTS Seven centers with a calorimeter available participated to the study. Due to slow inclusion rate, the study was stopped after 6 years and after inclusion of 417 patients only. From the 417 intended to treat patients, 339 followed the protocol. There was no differences between control and study groups in terms of age, sex BMI, SOFA (7.1 ± 3.1 vs 7.4 ± 3.3) and APACHE II scores (22.4 ± 7.9 vs 22.2 ± 7.4). The rate of infection (40 vs 31), including pneumonia rate, need for surgery, dialysis requirement, length of ventilation, ICU length of stay, and hospital length of stay were not different between groups. Mortality (30 in the control vs 21 in the study group) was not significantly different between groups. The decreased mortality observed in the study group when added to previous studies may have a positive effect on the meta-analysis previously published. CONCLUSION Tight Calorie Control guided by indirect calorimetry decreased the rate of infection and mortality but not significantly. This may be explained by the not relatively small sample size. There results together with the previous 4 prospective randomized studies, may improve the results of the meta-analysis exploring the effects of IC guided nutrition on mortality.
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Affiliation(s)
- P Singer
- Department of Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beillison Hospital, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel.
| | - E De Waele
- Department of Surgical ICU, UZ Brussel, Belgium.
| | - C Sanchez
- Hospital General Reina Sofía, Murcia, Spain.
| | - S Ruiz Santana
- Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
| | - J C Montejo
- Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | - A Soroksky
- Intensive Care Unit, Wolfson Medical Center, Holon, Israel.
| | - E Moscovici
- Department of Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beillison Hospital, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - I Kagan
- Department of Intensive Care, Institute for Nutrition Research, Rabin Medical Center, Beillison Hospital, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
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16
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Terblanche E, Remmington C. Observational study evaluating the nutritional impact of changing from 1% to 2% propofol in a cardiothoracic adult critical care unit. J Hum Nutr Diet 2020; 34:413-419. [PMID: 33211347 DOI: 10.1111/jhn.12835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Nutritional support in the critically ill aims to avoid under and overfeeding, adjusting to changes in energy expenditure during critical illness. The sedation propofol provides significant fat and energy load. We investigated whether changing from 1% to a 2% propofol, would decrease non-nutritional energy, avoid energy overfeeding and increase the amount of protein delivered. METHODS A retrospective observational study was performed. The primary outcome was protein delivery. Secondary outcomes were energy from propofol fat and the total energy delivered from nutrition and propofol. RESULTS In total, 100 patients were investigated, with 50 patients in each group. The propofol dose was comparable for each group. The nutrition energy prescribed was significantly less for the 1% compared to 2% group, taking the energy from propofol into consideration. Both groups had similar protein targets, although the amount delivered was significantly higher in the 2% group. Thirty-six percent of individuals receiving 1% exceeded 45% of total energy from fat. The poor delivery of nutrition resulted in inadequate energy and protein, irrespective of propofol dose. CONCLUSIONS We investigated the impact of propofol on energy overfeeding and under delivery of protein, and highlighted suboptimal nutritional provision. Work is needed to investigate the harm that high-fat delivery may pose in light of poor nutrition delivery.
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Affiliation(s)
- Ella Terblanche
- Adult Critical Care Unit, The Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, UK
| | - Chris Remmington
- Adult Critical Care Unit, The Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, UK
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17
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Koekkoek W, Xiaochen G, van Dijk D, van Zanten A. Resting energy expenditure by indirect calorimetry versus the ventilator-VCO2 derived method in critically ill patients: The DREAM-VCO2 prospective comparative study. Clin Nutr ESPEN 2020; 39:137-143. [DOI: 10.1016/j.clnesp.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 01/17/2023]
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18
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Rougier L, Preiser JC, Fadeur M, Verbrugge AM, Paquot N, Ledoux D, Misset B, Rousseau AF. Nutrition During Critical Care: An Audit on Actual Energy and Protein Intakes. JPEN J Parenter Enteral Nutr 2020; 45:951-960. [PMID: 32776591 DOI: 10.1002/jpen.1962] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/01/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Oral nutrition is delivered frequently in intensive care units (ICUs) but rarely studied. The primary objective of this study was to quantify nutrition intakes in patients exclusively orally fed (OF) and in those receiving medical nutrition solutions or both. METHODS Adults who stayed in a mixed ICU for ≥3 days were studied. Nutrition deficits were calculated as the difference between estimated energy or protein targets (determined by weight-based formulas) and actual intakes (recorded on a daily basis by nurses). Total volumes of enteral or parenteral nutrition solutions, propofol, and glucose infused over 24 hours were collected and energy and protein amounts were calculated. In OF patients, food intake at each meal (breakfast, lunch, and dinner) was estimated using the "one-quarter portion" method. RESULTS Among the 289 included patients aged 67 (57-75.5) years, 253 were fed and received, on average, 14.3 (7.8-19) kcal/kg/d and 0.53 (0.27-0.8) g/kg/d protein. In OF patients (n = 126), intakes were 9.7 (5.8-19) kcal/kg/d and 0.35 (0.17-0.57) g/kg/d protein. In the subset of OF patients with ICU stay ≥ 7 days (n = 37), respectively, 51% and 94% never received ≥80% of their energy and protein targets. CONCLUSION Nutrition intakes were lower by oral feeding compared with other exclusive or combined medical nutrition. Compared with the prescribed amounts, the deficit was larger for proteins than for energy.
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Affiliation(s)
- Loïc Rougier
- Department of Anaesthesiology, University Hospital, University of Liège, Liège, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marjorie Fadeur
- Multidisciplinary Nutrition Team, University Hospital, University of Liège, Liège, Belgium
| | - Anne-Marie Verbrugge
- Multidisciplinary Nutrition Team, University Hospital, University of Liège, Liège, Belgium
| | - Nicolas Paquot
- Multidisciplinary Nutrition Team, University Hospital, University of Liège, Liège, Belgium.,Department of Diabetes, Nutrition and Metabolic Diseases, University Hospital, University of Liège, Liège, Belgium
| | - Didier Ledoux
- Multidisciplinary Nutrition Team, University Hospital, University of Liège, Liège, Belgium.,Department of Intensive Care and Burn Centre, University Hospital, University of Liège, Liège, Belgium
| | - Benoit Misset
- Department of Intensive Care and Burn Centre, University Hospital, University of Liège, Liège, Belgium
| | - Anne-Françoise Rousseau
- Multidisciplinary Nutrition Team, University Hospital, University of Liège, Liège, Belgium.,Department of Intensive Care and Burn Centre, University Hospital, University of Liège, Liège, Belgium
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19
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Buckley CT, Van Matre ET, Fischer PE, Minard G, Dickerson RN. Improvement in Protein Delivery for Critically Ill Patients Requiring High-Dose Propofol Therapy and Enteral Nutrition. Nutr Clin Pract 2020; 36:212-218. [PMID: 32589810 DOI: 10.1002/ncp.10546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Patients with traumatic brain (TBI) injury often require a high dosage of propofol, which can provide an excessive caloric intake. We evaluated our strategy of using liquid protein supplement boluses concurrently with high protein-containing enteral nutrition (EN) formulas and formula rate reduction to avoid caloric overfeeding and inadequate protein intake. METHODS Adult patients (aged >17 years) with TBI admitted to the trauma intensive care unit (TICU) who received concurrent propofol and EN were retrospectively reviewed. Caloric intakes from propofol and EN were obtained. Actual protein intake was compared with projected protein intakes from high protein content and standard protein content enteral formulas when given at an isocaloric intake. RESULTS Fifty-one patients were enrolled. Average caloric intake from propofol was 356 ± 243 kcal/d or 5 ± 3 kcal/kg/d (range, <1-15 kcal/kg/d). Daily EN caloric intake ranged from 7 ± 4 kcal/kg/d (day 2) to 16 ± 9 kcal/kg/d (day 5; P < .001). Average protein intake ranged from 0.6 ± 0.4 g/kg/d (day 2) to 1.5 ± 0.7 g/kg/d (day 5; P < .001). The modified EN strategy resulted in daily delivery of 24%-38% more protein than an isocaloric regimen with a high protein-content formula and twice as much protein than the standard protein-content formula (P < .001). CONCLUSION The strategy of providing an EN regimen comprised liquid protein boluses, and high and very high protein-containing EN formulas at a reduced rate improved protein delivery without caloric overfeeding.
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Affiliation(s)
- Christopher T Buckley
- Department of Pharmacy Practice, Union University, College of Pharmacy, Jackson, Tennessee, USA
| | - Edward T Van Matre
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Peter E Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Gayle Minard
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- Department of Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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20
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Kaur M, Balakrishnan N, Kumar R, Bhatia P. Anesthetic management of an insulinoma patient with recurrent hypoglycemic seizures. Saudi J Anaesth 2020; 14:417-418. [PMID: 32934648 PMCID: PMC7458023 DOI: 10.4103/sja.sja_194_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/08/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Manbir Kaur
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - N Balakrishnan
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Rakesh Kumar
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
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21
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van Zanten ARH, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:368. [PMID: 31752979 PMCID: PMC6873712 DOI: 10.1186/s13054-019-2657-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/22/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge. METHODS This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey. RESULTS Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis. CONCLUSIONS During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a "victim" of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.
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Affiliation(s)
| | - Elisabeth De Waele
- Intensive Care Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Nutrition, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Nydahl P, Schuchhardt D, Jüttner F, Dubb R, Hermes C, Kaltwasser A, Mende H, Müller-Wolff T, Rothaug O, Schreiber T. Caloric consumption during early mobilisation of mechanically ventilated patients in Intensive Care Units. Clin Nutr 2019; 39:2442-2447. [PMID: 31732289 DOI: 10.1016/j.clnu.2019.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/14/2019] [Accepted: 10/27/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate a) the magnitude of the increase in caloric consumption due to early mobilisation of patients with mechanical ventilation (MV) in Intensive Care Units (ICU) as part of routine care, b) whether there are differences in caloric consumption due to active or passive mobilisation, and c) whether early mobilisation in routine care would lead to additional nutritional requirements. DESIGN Prospective, observational, multi-centre study. SETTING Medical, surgical and neurological ICUs from three centres. PATIENTS Patients on MV in ICU who were mobilised out of bed as part of routine care. MEASUREMENTS AND MAIN RESULTS Caloric consumption was assessed in 66 patients by indirect calorimetry at six time points: (1) lying in bed 5-10 min prior to mobilisation, (2) sitting on the edge of the bed, (3) standing beside the bed, (4) sitting in a chair, (5) lying in bed 5-10 min after mobilisation, and (6) 2 h after mobilisation. Differences in caloric consumption in every mobilisation level vs. the baseline of lying in bed were measured for 5 min and found to have increased significantly by: +0.4 (Standard Deviation (SD) 0.59) kcal while sitting on the edge of the bed, +1.5 (SD 1.26) kcal while standing in front of the bed, +0.7 (SD 0.63) kcal while sitting in a chair (all p < 0.001). Active vs. passive transfers showed a higher, but non-significant consumption. A typical sequence of mobilisation including sitting on edge of the bed, standing beside the bed, sitting in a chair (20 min) and transfer back into bed, would require an additional 4.56 kcal compared to caloric consumption without mobilisation. CONCLUSIONS Based on this data, routine mobilisation of MV patients in ICU increases caloric consumption, especially in active mobilisation. Nevertheless, an additional caloric intake because of routine mobilisation does not seem to be necessary.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Germany.
| | - Danny Schuchhardt
- Wound Care ICW, Central Hospital Bad Berka GmbH, Bad Berka, Germany.
| | - Felix Jüttner
- Critical Care Nurse, AHA Instructor, Asklepios Klinik Langen, Langen, Germany.
| | - Rolf Dubb
- Department of Continuing Education Emergency Care, Anaesthesia and Intensive Care at the Academy of District Hospital Reutlingen GmbH, Reutlingen, Germany.
| | - Carsten Hermes
- CCRN, Business Administration (social and Health Care, IHK), Bonn, Germany.
| | - Arnold Kaltwasser
- Training Intensive in the Educational Institutions of the District Hospitals Reutlingen GmbH, Reutlingen, Germany.
| | - Hendrik Mende
- Neurological Intensive Care Unit, Christophsbad GmbH & Co. KG Specialist Hospital, Göppingen, Germany.
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Lopez-Delgado JC, Muñoz-del Rio G, Flordelís-Lasierra JL, Putzu A. Nutrition in Adult Cardiac Surgery: Preoperative Evaluation, Management in the Postoperative Period, and Clinical Implications for Outcomes. J Cardiothorac Vasc Anesth 2019; 33:3143-3162. [DOI: 10.1053/j.jvca.2019.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 04/05/2019] [Accepted: 04/07/2019] [Indexed: 02/07/2023]
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Monitoring nutrition in the ICU. Clin Nutr 2019; 38:584-593. [DOI: 10.1016/j.clnu.2018.07.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 12/21/2022]
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Allen K, Hoffman L. Enteral Nutrition in the Mechanically Ventilated Patient. Nutr Clin Pract 2019; 34:540-557. [PMID: 30741491 DOI: 10.1002/ncp.10242] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Mechanically ventilated patients are unable to take food orally and therefore are dependent on enteral nutrition for provision of both energy and protein requirements. Enteral nutrition is supportive therapy and may impact patient outcomes in the intensive care unit. Early enteral nutrition has been shown to decrease complications and hospital length of stay and improve the prognosis at discharge. Nutrition support is unique for patients on mechanical ventilation and, as recently published literature shows, should be tailored to the individuals' underlying pathology. This review will discuss the most current literature and recommendations for enteral nutrition in patients receiving mechanical ventilation.
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Affiliation(s)
- Karen Allen
- Section of Pulmonary and Critical Care, The University of Oklahoma Health Sciences Center and VA Medical Center Oklahoma City, Oklahoma City, Oklahoma, USA
| | - Leah Hoffman
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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The Effect of Nutrition on Early Stress-Induced Hyperglycemia, Serum Insulin Levels, and Exogenous Insulin Administration in Critically Ill Patients With Septic Shock: A Prospective Observational Study. Shock 2018; 52:e31-e38. [PMID: 30407371 DOI: 10.1097/shk.0000000000001287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Stress-induced hyperglycemia is common among septic shock patients. Nutritional support influences glucose homeostasis but this effect has never been studied in septic shock. We aimed to determine the course of hyperglycemia and serum insulin levels in critically ill septic shock patients and to address the effects of caloric intake on glycemia, insulin levels, and exogenous insulin requirements. METHODS A prospective observational study of 24 ventilated septic shock patients during 72 h after ICU admission. Every 4 h nutritional variables, exogenous insulin administration, serum insulin, and glucose levels were recorded. RESULTS Stress-induced hyperglycemia was found in 96.2% of patients. Exogenous insulin requirements increased gradually and were most pronounced at 36 h (mean 4.64 IU/h). Total serum insulin levels were lowest at the point of most exogenous insulin requirements (mean 2.75 mIU/L). Total caloric intake and insulin requirements were positively associated (Pearson correlation coefficient 0.210). CONCLUSIONS In patients with septic shock marked reduced serum insulin levels can be observed during the first 36 h after intensive care unit (ICU) admission that have to be compensated by exogenous insulin administration, a phenomenon gradually improving after 36 h. Feeding is positively associated with exogenous insulin requirements. These results suggest that strategies to manage stress-induced hyperglycemia in patients with septic shock should consider frequent glycemic monitoring, conservative insulin dosing to prevent hypoglycemia when insulin resistance disappears, and slow progressive nutrition support during the early ICU phase as caloric loading may worsen hyperglycemia. This approach may attenuate the risk of glucose variability, hypo- and hyperglycemia and associated poor outcomes.
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Olthof LE, Koekkoek WK, van Setten C, Kars JC, van Blokland D, van Zanten AR. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study. Clin Nutr 2018; 37:1609-1617. [DOI: 10.1016/j.clnu.2017.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/08/2017] [Accepted: 08/03/2017] [Indexed: 12/15/2022]
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1300] [Impact Index Per Article: 216.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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Hastings J, Ridley EJ, Bianchet O, Roodenburg O, Levkovich B, Scheinkestel C, Pilcher D, Udy A. Does Propofol Sedation Contribute to Overall Energy Provision in Mechanically Ventilated Critically Ill Adults? A Retrospective Observational Study. JPEN J Parenter Enteral Nutr 2017; 42:748-757. [PMID: 28800404 DOI: 10.1177/0148607117721917] [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: 01/26/2017] [Accepted: 06/30/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND Propofol sedation is common in critically ill patients, providing energy of 1.1 kcal/mL when administered as a 1% solution. We aimed to determine the proportion of energy administered as propofol on days 1-5 in the intensive care unit (ICU) and any association with outcomes. METHODS Retrospective observational study in a quaternary ICU from January-December 2012. Inclusion criteria were length of stay (LOS) ≥5 days, age ≥18 years, and provision of mechanical ventilation (MV) for ≥5 days. Outcome measures included proportion of total daily energy provided as propofol, overall energy balance, hospital mortality, duration of MV, and ICU LOS. RESULTS Data from 370 patients were analyzed, 87.8% (n = 325) of whom received propofol during days 1-5 in ICU. A median [interquartile range (IQR)] of 119 [50-730] kcal was provided as propofol per patient-day. Proportion of energy provided by propofol as a percentage of total energy delivered was 55.4%, 15.4%, 9.3%, 7.9%, and 9.9% days 1-5, respectively. Patients administered propofol received a greater proportion of their total daily energy prescription compared with those who were not (P < .01). Proportion of energy provided as propofol was not significantly different based on hospital mortality (P = .62), duration of MV (P = .50), or ICU LOS (P = .15). CONCLUSION Propofol contributes to overall energy intake on days 1-5 of ICU admission. Energy balance was higher in those receiving propofol. No association was found between the proportion of energy delivered as propofol and outcomes.
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Affiliation(s)
- Jennifer Hastings
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Emma J Ridley
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia.,Nutrition and Dietetics Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Oliver Bianchet
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Owen Roodenburg
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Bianca Levkovich
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Carlos Scheinkestel
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Monash Medical Centre, Clayton, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
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New AM, Nystrom EM, Frazee E, Dillon JJ, Kashani KB, Miles JM. Continuous renal replacement therapy: a potential source of calories in the critically ill. Am J Clin Nutr 2017; 105:1559-1563. [PMID: 28468893 PMCID: PMC6546225 DOI: 10.3945/ajcn.116.139014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 03/29/2017] [Indexed: 01/04/2023] Open
Abstract
Background: Overfeeding can lead to multiple metabolic and clinical complications and has been associated with increased mortality in the critically ill. Continuous venovenous hemofiltration (CVVH) represents a potential source of calories that is poorly recognized and may contribute to overfeeding complications.Objective: We aimed to quantify the systemic caloric contribution of acid-citrate-dextrose regional anticoagulation and dextrose-containing replacement fluids in the CVVH circuit.Design: This was a prospective study in 10 critically ill adult patients who received CVVH from April 2014 to June 2014. Serial pre- and postfilter blood samples (n = 4 each) were drawn and analyzed for glucose and citrate concentrations on each of 2 consecutive days.Results: Participants included 5 men and 5 women with a mean ± SEM age of 61 ± 4 y (range: 42-84 y) and body mass index (in kg/m2) of 28 ± 2 (range: 18.3-36.2). There was generally good agreement between data on the 2 study days (CV: 7-11%). Mean ± SEM pre- and postfilter venous plasma glucose concentrations in the aggregate group were 152 ± 10 and 178 ± 9 mg/dL, respectively. Net glucose uptake from the CVVH circuit was 54 ± 5 mg/min and provided 295 ± 28 kcal/d. Prefilter plasma glucose concentrations were higher in patients with diabetes (n = 5) than in those without diabetes (168 ± 12 compared with 140 ± 14 mg/dL; P < 0.05); however, net glucose uptake was similar (46 ± 8 compared with 61 ± 6 mg/min; P = 0.15). Mean ± SEM pre- and postfilter venous plasma citrate concentrations were 1 ± 0.1 and 3.1 ± 0.2 mmol/L, respectively. Net citrate uptake from the CVVH circuit was 60 ± 2 mg/min and provided 218 ± 8 kcal/d.Conclusions: During CVVH there was a substantial net uptake of both glucose and citrate that delivered exogenous energy and provided ∼512 kcal/d. Failure to account for this source of calories in critically ill patients receiving nutrition on CVVH may result in overfeeding.
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Affiliation(s)
| | | | | | | | | | - John M Miles
- Endocrine Research Unit, Mayo Clinic, Rochester, MN
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Abstract
PURPOSE OF REVIEW To summarize recent relevant studies regarding nutrition during critical illness and provide recommendations for clinical practice. RECENT FINDINGS Recently acquired knowledge regarding nutritional status and risk assessment, body composition, gastric residual volume, prokinetics, tube positioning, enteral vs parenteral nutrition, nutritional dose and timing of initiation, pharmaconutrition, dysbiosis and probiotics are discussed. SUMMARY Body composition especially lean body mass is associated with clinical outcomes. The modified NUTrition Risk in the Critically ill score was validated for nutritional risk assessment and identifies patients that benefit from higher nutritional intake; however, caloric restriction decreases mortality in refeeding syndrome. Gastric residual volume monitoring is debated, as abandoning its application doesn't worsen outcome. There is no consensus regarding benefits of gastric vs postpyloric tube placement. Current prokinetics temporarily reduce feeding intolerance, new prokinetics are developed. Enteral remains preferable over parenteral nutrition, although no inferiority of parenteral nutrition is reported in recent studies. Studies imply no harm of hypocaloric feeding when protein requirements are met. Optimal protein provision may be more important than caloric adequacy. Pharmaconutrition confers no superior outcomes and may even confer harm. Dysbiosis is frequently encountered and associated with worse outcomes. Probiotics reduce infectious complications, but not mortality, and may contribute to earlier recovery of gut function.
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