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Araújo F, Posadas-Calleja JG, Raman M, Tosh M, Wischmeyer P, Barreto P, Gillis C. Association between protein intake and functional capacity in critically ill patients: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024. [PMID: 39018085 DOI: 10.1002/jpen.2673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Intensive care unit (ICU) protein benchmarks are based on mortality and morbidity; whether these targets also support functional recovery is unknown. We assessed whether different protein doses influenced patients' functional capacity, measured by the Chelsea Physical Assessment score (CPAx). METHODS Single-center retrospective cohort study on ICU survivors with length of stay ≥7 days admitted between October 2014 and September 2020. Eligible patients were divided according to protein intake (g/kg/day): low (<0.8), medium (0.8-1.19), high (1.2-1.5), and very high (>1.5). Protein dose effect on CPAx was assessed at ICU discharge with analysis of covariance adjusting for age, illness severity, hospital length of stay before ICU admission, time to start nutrition support, and mechanical ventilation duration. We also investigated effect modification by energy intake and nutrition status. RESULTS Enrolled patients (n = 531) were similar for age, nutrition status, and illness severity across groups. CPAxs were nonlinearly associated with protein doses and similar among low, medium, and very high groups. The CPAx for the high group was statistically different (P = 0.014), indicating that the data of three groups could be pooled. Mean CPAx difference remained statistically significant after adjusting for confounding variables (3.9 ± 1.8, P = 0.029 in the four-group model, and 2.7 ± 0.9, P = 0.003 in the pooled two-group model). Energy intake was equivalent between groups and did not modify CPAx. The high group had superior CPAx in both well-nourished and malnourished patients, indicating nutrition status was not an effect modifier. CONCLUSION Protein dose 1.2-1.5 g/kg/day was associated with superior functional capacity at ICU discharge compared with other doses. Neither energy intake nor nutrition status modified functional capacity across groups; therefore, the results appear to be influenced by 1.2-1.5 g/kg/day.
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Affiliation(s)
- Fábio Araújo
- Department of Nutrition Services, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Maitreyi Raman
- Division of Gastroenterology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maureen Tosh
- Department of Rehabilitation, Alberta Health Services, Calgary, Alberta, Canada
| | - Paul Wischmeyer
- Department of Anesthesiology & Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Priscilla Barreto
- Department of Nutrition Services, Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Quebec, Canada
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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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3
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Pardo E, Lescot T, Preiser JC, Massanet P, Pons A, Jaber S, Fraipont V, Levesque E, Ichai C, Petit L, Tamion F, Taverny G, Boizeau P, Alberti C, Constantin JM, Bonnet MP. Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study. Crit Care 2023; 27:7. [PMID: 36611211 PMCID: PMC9826592 DOI: 10.1186/s13054-022-04298-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Current guidelines suggest the introduction of early nutrition support within the first 48 h of admission to the intensive care unit (ICU) for patients who cannot eat. In that context, we aimed to describe nutrition practices in the ICU and study the association between the introduction of early nutrition support (< 48 h) in the ICU and patient mortality at day 28 (D28) using data from a multicentre prospective cohort. METHODS The 'French-Speaking ICU Nutritional Survey' (FRANS) study was conducted in 26 ICUs in France and Belgium over 3 months in 2015. Adult patients with a predicted ICU length of stay > 3 days were consecutively included and followed for 10 days. Their mortality was assessed at D28. We investigated the association between early nutrition (< 48 h) and mortality at D28 using univariate and multivariate propensity-score-weighted logistic regression analyses. RESULTS During the study period, 1206 patients were included. Early nutrition support was administered to 718 patients (59.5%), with 504 patients receiving enteral nutrition and 214 parenteral nutrition. Early nutrition was more frequently prescribed in the presence of multiple organ failure and less frequently in overweight and obese patients. Early nutrition was significantly associated with D28 mortality in the univariate analysis (crude odds ratio (OR) 1.69, 95% confidence interval (CI) 1.23-2.34) and propensity-weighted multivariate analysis (adjusted OR (aOR) 1.05, 95% CI 1.00-1.10). In subgroup analyses, this association was stronger in patients ≤ 65 years and with SOFA scores ≤ 8. Compared with no early nutrition, a significant association was found of D28 mortality with early enteral (aOR 1.06, 95% CI 1.01-1.11) but not early parenteral nutrition (aOR 1.04, 95% CI 0.98-1.11). CONCLUSIONS In this prospective cohort study, early nutrition support in the ICU was significantly associated with increased mortality at D28, particularly in younger patients with less severe disease. Compared to no early nutrition, only early enteral nutrition appeared to be associated with increased mortality. Such findings are in contrast with current guidelines on the provision of early nutrition support in the ICU and may challenge our current practices, particularly concerning patients at low nutrition risk. Trial registration ClinicalTrials.gov Identifier: NCT02599948. Retrospectively registered on November 5th 2015.
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Affiliation(s)
- Emmanuel Pardo
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance publique-hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | - Thomas Lescot
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance publique-hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Jean-Charles Preiser
- Service des Soins intensifs, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pablo Massanet
- Département Anesthésie-Réanimation, Centre Hospitalier Universitaire Nîmes, 30000, Nîmes, France
| | - Antoine Pons
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris, 75013, Paris, France
| | - Samir Jaber
- Department of Anaesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier. PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier Cedex 5, France
| | - Vincent Fraipont
- Service de Soins Intensifs, Centre Hospitalier Régional de Liège, 4000, Liège, Citadelle, Belgium
| | - Eric Levesque
- Service d'anesthésie-réanimation chirurgicale, GHU Henri-Mondor, 94000, Créteil, France
| | - Carole Ichai
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Département Anesthésie-Réanimation, Nice, France
| | - Laurent Petit
- Service de réanimation chirurgicale et traumatologique Pellegrin place Amélie Raba-Léon, 33000, Bordeaux, France
| | - Fabienne Tamion
- Service de Médecine Intensive Réanimation, CHU Rouen, Université de Normandie, UNIROUEN, INSERM U1096, 76000, Rouen, France
| | - Garry Taverny
- AP-HP, Hôpital Robert-Debré, Unité d'Epidémiologie Clinique, 48 bd Serurier, 75019, Paris, France
| | - Priscilla Boizeau
- AP-HP, Hôpital Robert-Debré, Unité d'Epidémiologie Clinique, 48 bd Serurier, 75019, Paris, France
| | - Corinne Alberti
- AP-HP, Hôpital Robert-Debré, Unité d'Epidémiologie Clinique, 48 bd Serurier, 75019, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Assistance publique-hôpitaux de Paris, 75013, Paris, France
| | - Marie-Pierre Bonnet
- Sorbonne Université, Département Anesthésie-Réanimation, Hôpital Armand Trousseau, DMU DREAM, GRC 29, AP-HP, Paris, France
- Université Paris Cité, INSERM, INRA, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Maternité Port Royal, 53 avenue de l'Observatoire, 75014, Paris, France
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Trajectories of protein intake and 28-day mortality in critically ill patients: A secondary analysis of a cluster-randomized controlled trial. Clin Nutr 2022; 41:1644-1650. [DOI: 10.1016/j.clnu.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/18/2022]
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Abu Hafsa SH, Senbill H, Basyony MM, Hassan AA. Amelioration of Sarcoptic Mange-Induced Oxidative Stress and Growth Performance in Ivermectin-Treated Growing Rabbits Using Turmeric Extract Supplementation. Animals (Basel) 2021; 11:2984. [PMID: 34680003 PMCID: PMC8532694 DOI: 10.3390/ani11102984] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 12/05/2022] Open
Abstract
In this experiment, the protective effect of turmeric extract (TE) on side effects of Ivermectin-treated rabbits, while improving their performance, blood characteristics, and antioxidant status, was investigated. Sixty-three clinically Sarcoptes-infested rabbits aged 60 days were randomly allocated into three groups, with 21 rabbits in each group, to receive either no TE or TE supplementation (1 or 2 mg/kg diet) for 30 days after being subcutaneously injected with Ivermectin (IVM) 1% w/v at a dose of 0.2 mg/kg body weight twice a week. Another 21 healthy rabbits were used as the control. Treatment with IVM + 1 and 2 mg TE improved body weight (BW), body weight gain (BWG), feed intake (FI), and feed conversion ratio (FCR) in infested rabbits (p < 0.05). The IVM alone treatment had the highest mortality rate compared with the other treatments. Rabbits treated with IVM + 1 and 2 mg TE demonstrated progressive recovery manifested by improved nutrient digestibility and nitrogen balance. On day 7, the serum total protein, albumin, and albumin/globulin (A/G) ratio were significantly lower in the treated groups compared with the control group; also, the lowest values were observed in rabbits treated only with Ivermectin, followed by IVM + 1 and 2 mg TE. Treated rabbits had higher thiobarbituric acid reactive substance (TBAR) levels, but lower total antioxidant capacity (TAC), superoxidase dismutase (SOD), and glutathion peroxidase (GSH-Px) levels compared with the control group. On day 30 post-treatment, the rabbits in the IVM + 1 and 2 mg TE treatment groups showed progressive recovery manifested by improved biochemichal parameters, as well as a remarkable improvements in the oxidant/antioxidant balance towards normalcy (p < 0.05), and became comparable to that of the control compared with IVM alone treatment. In conclusion, turmeric extract improved rabbits' performance toward normalcy, and has remarkable antioxidant properties and can be used in conjunction with a miticide to treat sarcoptic mange in rabbits.
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Affiliation(s)
- Salma H. Abu Hafsa
- Livestock Research Department, Arid Lands Cultivation Research Institute, City of Scientific Research and Technological Applications, New Borg El-Arab, Alexandria 21934, Egypt
| | - Haytham Senbill
- Department of Applied Entomology and Zoology, Faculty of Agriculture, Alexandria University, Alexandria 21545, Egypt;
| | - Mohamed M. Basyony
- Agricultural Research Center, Animal Production Research Institute, Giza 12619, Egypt; (M.M.B.); (A.A.H.)
| | - Ayman A. Hassan
- Agricultural Research Center, Animal Production Research Institute, Giza 12619, Egypt; (M.M.B.); (A.A.H.)
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Wu X, Wu J, Wang P, Fang X, Yu Y, Tang J, Xiao Y, Wang M, Li S, Zhang Y, Hu B, Ma T, Li Q, Wang Z, Wu A, Liu C, Dai M, Ma X, Yi H, Kang Y, Wang D, Han G, Zhang P, Wang J, Yuan Y, Wang D, Wang J, Zhou Z, Ren Z, Liu Y, Guan X, Ren J. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis 2021; 71:S337-S362. [PMID: 33367581 DOI: 10.1093/cid/ciaa1513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.
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Affiliation(s)
- Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,BenQ Medical Center, Nanjing Medical University, Nanjing, China
| | - Peige Wang
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueling Fang
- Department of Critical Care Medicine, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Tang
- Department of Emergency Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Yonghong Xiao
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shikuan Li
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Li
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiming Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Menghua Dai
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Huimin Yi
- Department of Critical Care Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gang Han
- Department of Gastroenterology, Second Hospital of Jilin University, Changchun, China
| | - Ping Zhang
- Department of General Surgery, First Hospital of Jilin University, Changchun, China
| | - Jianzhong Wang
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yufeng Yuan
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Wang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Wang
- Department of Biliary and Pancreatic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Zhou
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zeqiang Ren
- Department of General Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuxiu Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Whole-body protein kinetic models to quantify the anabolic response to dietary protein consumption. CLINICAL NUTRITION OPEN SCIENCE 2021. [DOI: 10.1016/j.nutos.2021.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Comprehensive metabolic amino acid flux analysis in critically ill patients. Clin Nutr 2021; 40:2876-2897. [PMID: 33946038 DOI: 10.1016/j.clnu.2021.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 01/16/2023]
Abstract
Amino acid (AA) metabolism is severely disturbed in critically ill ICU patients. To be able to make a more scientifically based decision on the type of protein or AA nutrition to deliver in ICU patients, comprehensive AA phenotyping with measurements of plasma concentrations and whole body production (WBP) is needed. Therefore, we studied ICU patients and matched control subjects using a novel pulse isotope method to obtain in-depth metabolic analysis. In 51 critically ill ICU patients (SOFA~6.6) and 49 healthy controls, we measured REE and body composition/phase-angle using BIA. In the postabsorptive state, we collected arterial (ized) blood for CRP and AA. Then, we administered an 8 mL solution containing 18 stable AA tracers as a pulse and calculated WBP. Enrichments: LC-MS/MS and statistics: t-test, ANCOVA. Compared to healthy, critically ill ICU patients had lower phase-angle (p < 0.00001), and higher CRP (p < 0.0001). Most AA concentrations were lower in ICU patients (p < 0.0001), except tau-methylhistidine and phenylalanine. WBP of most AA were significantly (p < 0.0001) higher with increases in glutamate (160%), glutamine (46%), and essential AA. Remarkably, net protein breakdown was lower. There were only weak relationships between AA concentrations and WBP. Critically ill ICU patients (SOFA 8-16) had lower values for phase angle (p = 0.0005) and small reductions of most plasma AA concentrations, but higher tau-methylhistidine (p = 0.0223) and hydroxyproline (p = 0.0028). Remarkably, the WBP of glutamate and glutamine were lower (p < 0.05), as was their clearance, but WBP of tau-methylhistidine (p = 0.0215) and hydroxyproline (p = 0.0028) were higher. Our study in critically ill ICU patients shows that comprehensive metabolic phenotyping was able to reveal severe disturbances in specific AA pathways, in a disease severity dependent way. This information may guide improving nutritional compositions to improve the health of the critically ill patient. CLINICAL TRIAL REGISTRY: Data are from the baseline measurements of study NCT02770092 (URL: https://clinicaltrials.gov/ct2/show/NCT02770092) and NCT03628365 (URL: https://clinicaltrials.gov/ct2/show/NCT03628365).
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9
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Sundström Rehal M, Liebau F, Wernerman J, Rooyackers O. Whole-body protein kinetics in critically ill patients during 50 or 100% energy provision by enteral nutrition: A randomized cross-over study. PLoS One 2020; 15:e0240045. [PMID: 33017434 PMCID: PMC7535026 DOI: 10.1371/journal.pone.0240045] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/16/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Enteral nutrition (EN) is a ubiquitous intervention in ICU patients but there is uncertainty regarding the optimal dose, timing and importance for patient-centered outcomes during critical illness. Our research group has previously found an improved protein balance during normocaloric versus hypocaloric parenteral nutrition in neurosurgical ICU patients. We now wanted to investigate if this could be demonstrated in a general ICU population with established enteral feeding, including patients on renal replacement therapy. METHODS Patients with EN >80% of energy target as determined by indirect calorimetry were randomized to or 50% or 100% of current EN rate. After 24 hours, whole-body protein kinetics were determined by enteral and parenteral stable isotope tracer infusions. Treatment allocation was then switched, and tracer investigations repeated 24 hours later in a crossover design with patients serving as their own controls. RESULTS Six patients completed the full protocol. During feeding with 100% EN all patients received >1.2 g/kg/day of protein. Mean whole-body protein balance increased from -6.07 to 2.93 µmol phenylalanine/kg/h during 100% EN as compared to 50% (p = 0.044). The oxidation rate of phenylalanine was unaltered (p = 0.78). CONCLUSIONS It is possible to assess whole-body protein turnover using a stable isotope technique in critically ill patients during enteral feeding and renal replacement therapy. Our results also suggest a better whole-body protein balance during full dose as compared to half dose EN. As the sample size was smaller than anticipated, this finding should be confirmed in larger studies.
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Affiliation(s)
- Martin Sundström Rehal
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Felix Liebau
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
- Division of Anesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Suzuki G, Ichibayashi R, Yamamoto S, Serizawa H, Nakamichi Y, Watanabe M, Honda M. Effect of high-protein nutrition in critically ill patients: A retrospective cohort study. Clin Nutr ESPEN 2020; 38:111-117. [PMID: 32690144 DOI: 10.1016/j.clnesp.2020.05.022] [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: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Early provision of a high-protein nutrition improves the prognosis of patients in intensive care units (ICUs). However, high protein intake increases blood urea nitrogen (BUN). No study has compared outcomes according to protein intake, and the clinical significance of changes in BUN (ΔBUN) in ICU patients is unclear. Here, we investigated the association of high protein intake with outcomes and BUN and assessed the clinical significance of ΔBUN. METHODS This was a single-center retrospective cohort study. Between 1 January 2016 and 30 September 2019, 295 ICU patients received enteral nutrition for at least 3 days while undergoing mechanical ventilation. After applying the exclusion criteria of an age of <18 years, gastrointestinal disease, maintenance dialysis, renal replacement therapy after admission, kidney transplantation, and death within 7 days of commencing enteral nutrition, 206 patients remained. INTERVENTIONS Participants were divided into those receiving >1.2 g/kg/day of protein (high-protein group; n = 111) and those receiving ≤1.2 g/kg/day of protein (non-high-protein group; n = 95). The groups were balanced by propensity score matching. The primary endpoint was 28-day mortality, and the secondary endpoints were 90-day mortality, length of ICU stay, number of ventilator-free days in the first 28 days, and ΔBUN. RESULTS The high-protein group had significantly lower 28- and 90-day mortality and significantly greater ΔBUN, including after propensity score matching. ΔBUN might not be associated with outcomes. CONCLUSIONS Provision of >1.2 g/kg/day of protein may be associated with lower mortality of tube-fed and mechanically ventilated patients. Furthermore, while high protein intake may be associated with higher BUN, these changes may not be adversely associated with outcomes.
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Affiliation(s)
- Ginga Suzuki
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Ryo Ichibayashi
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Saki Yamamoto
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Hibiki Serizawa
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Yoshimi Nakamichi
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Masayuki Watanabe
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
| | - Mitsuru Honda
- Critical Care Center, Toho University Omori Medical Center, Tokyo, Japan.
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11
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Mousavian SZ, Pasdar Y, Ranjbar G, Jandari S, Akhlaghi S, Almasi A, Safarian M. Randomized Controlled Trial of Comparative Hypocaloric vs Full-Energy Enteral Feeding During the First Week of Hospitalization in Neurosurgical Patients at the Intensive Care Unit. JPEN J Parenter Enteral Nutr 2020; 44:1475-1483. [PMID: 32167611 DOI: 10.1002/jpen.1782] [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: 07/19/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutrition support plays a pivotal role in improving the clinical outcomes of the patients admitted to the intensive care unit (ICU). However, there are controversies regarding the optimal amount of energy for the reduction of morbidity and mortality in neurosurgical patients at the ICU. METHODS This randomized clinical trial was conducted on 560 patients who were admitted to trauma, stroke, and neurosurgery ICUs, and 68 patients were enrolled based on the inclusion criteria. In total, data of 58 patients were analyzed. In the full-energy group, enteral feeding started at 75% of their daily energy expenditure and gradually increased to 90%-100%. In the hypocaloric group, enteral feeding started with 30% of the daily energy expenditure and reached 75% within 7 days of the intervention. RESULTS No significant differences were observed in the baseline characteristics of the patients in the hypocaloric and full-energy groups. The incidence of severe gastrointestinal intolerance was relatively high in the full-energy group (P < .001). Duration of mechanical ventilation and length of hospital stay were lower in the hypocaloric group compared with the full-energy group (P = .014 and P = .046, respectively). However, no significant differences were denoted in the length of ICU admission (P = .163), 28-day mortality (P = .640), and pneumonia (P = .162) between the study groups. CONCLUSIONS In the neurocritical care unit, hypocaloric enteral feeding was associated with lower gastrointestinal intolerance, as well as reduced duration of ventilator dependence and length of hospital stay.
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Affiliation(s)
- Seyedeh Zeynab Mousavian
- Student Research Committee, Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yahya Pasdar
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Golnaz Ranjbar
- Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajedeh Jandari
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Akhlaghi
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afshin Almasi
- Research Center of Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Safarian
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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12
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Leyderman I, Yaroshetskiy A, Klek S. Protein Requirements in Critical Illness: Do We Really Know Why to Give So Much? JPEN J Parenter Enteral Nutr 2020; 44:589-598. [PMID: 32043628 DOI: 10.1002/jpen.1792] [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: 02/26/2019] [Revised: 12/27/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
The protein and energy requirements of critically ill patients treated in intensive care units (ICUs) have been actively discussed recently. Currently published clinical recommendations and reviews suggest significant increases of protein provision to 2-2.5 g/kg/d in some populations of ICU patients. However, a detailed analysis of the main sources of these recommendations reveals a number of serious contradictions, as well as an absence of obvious evidence supporting the allotment of high doses of protein. We went through these recommendations and reviewed cited articles and other studies, and we have separated our arguments against excessive protein provision into sections.
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Affiliation(s)
- Ilya Leyderman
- Intensive Care Unit, Ural State Medical University, Yekaterinburg, Russia
| | - Andrey Yaroshetskiy
- Vorokhobov Municipal Clinical Hospital No. 67, Intensive Care Unit, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Stanislaw Klek
- General Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
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13
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Gostyńska A, Stawny M, Dettlaff K, Jelińska A. Clinical Nutrition of Critically Ill Patients in the Context of the Latest ESPEN Guidelines. ACTA ACUST UNITED AC 2019; 55:medicina55120770. [PMID: 31810303 PMCID: PMC6955661 DOI: 10.3390/medicina55120770] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/21/2019] [Accepted: 11/26/2019] [Indexed: 01/01/2023]
Abstract
The group of patients most frequently in need of nutritional support are intensive care patients. This year (i.e., 2019), new European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines of clinical nutrition in intensive care were published, updating and gathering current knowledge on the subject of this group of patients. Planning the right nutritional intervention is often a challenging task involving the necessity of the choice of the enteral nutrition (EN) or parenteral nutrition (PN) route of administration, time of initiation, energy demand, amino acid content and demand as well as the use of immunomodulatory nutrition. The aim of this study was to specify and discuss the basic aspects of the clinical nutrition of critically ill patients recommended by ESPEN guidelines. Clinical nutrition in intensive care seems to be the best-studied type of nutritional intervention. However, meta-analyses and clinical studies comparing EN and PN and their impact on the prognosis of the intensive care patients showed ambiguous results. The nutritional interventions, starting with EN, should be initiated within 24-48 h whereas PN, if recommended, should be implemented within 3-7 days. The recommended method of calculation of the energy demand is indirect calorimetry, however, there are also validated equations used worldwide in everyday practice. The recommended protein intake in this group of patients and the results of insufficient or too high supply was addressed. In light of the concept of immunomodulatory nutrition, the use of appropriate amino acid solutions and lipid emulsion that can bring a positive effect on the modulation of the immune response was discussed.
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14
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Association between enteral nutrition support and neurological outcome in patients with acute intracranial haemorrhage: A retrospective cohort study. Sci Rep 2019; 9:16507. [PMID: 31712731 PMCID: PMC6848122 DOI: 10.1038/s41598-019-53100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022] Open
Abstract
Association between the amount of enteral nutrition (EN) caloric intake and Glasgow coma scale scores at discharge (GCSdis) in intracranial haemorrhage (ICH) was retrospectively investigated in 230 patients in a single center from 2015 and 2017. GCSdis was used as a dichotomous outcome (≤8 or >8: 56/230 vs. 174/230) and its association with the amount of EN caloric intake within 48 hours was analysed in four logistic models. Model 1 used EN as a continuous variable and showed association with favourable GCSdis (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01–1.08). Models 2 and 3 categorized EN into two (≤25 and >25 kcal/kg/48 hrs) and three caloric intake levels (≤10, 10~25, and >25 kcal/kg/48 hrs) respectively, and compared them with the lowest level; highest EN level associated with favourable GCSdis in both model 2 (OR, 2.77; 95%CI, 1.25–6.13) and 3 (OR, 4.68; 95%CI, 1.61–13.61). Model 4 transformed EN into four quartiles (Q1-Q4). Compared to Q1, OR increased stepwise from Q2 (OR 1.80, 95%CI 0.59–5.44) to Q4 (OR 4.71, 95%CI 1.49–14.80). Propensity score matching analysis of 69 matched pairs demonstrated consistent findings. In the early stage of ICH, increased EN was associated with favourable GCSdis.
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15
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Heyland DK, Day A, Clarke GJ, Hough CT, Files DC, Mourtzakis M, Deutz N, Needham DM, Stapleton R. Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness. BMJ Open 2019; 9:e027893. [PMID: 31371287 PMCID: PMC6678006 DOI: 10.1136/bmjopen-2018-027893] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU). METHODS AND ANALYSIS In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses. ETHICS AND DISSEMINATION The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms. TRIAL REGISTRATION NUMBER NCT03021902; Pre-results.
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Affiliation(s)
- Daren K Heyland
- Critical Care, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Department of Community Health and Epidemiology and CERU, Queen's Unversity, Kingston, Ontario, Canada
| | - G John Clarke
- Critical Evalulation Research Unit, Queen's University, Kingston, Ontario, Canada
| | - Catherine Terri Hough
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - D Clark Files
- Pulmonary, Critical Care, Allergy and Immunology Division, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marina Mourtzakis
- University of Waterloo Faculty of Applied Health Sciences, Waterloo, Ontario, Canada
| | - Nicolaas Deutz
- Department of Health and Kinesiology, Texas A&M University, College Station, Texas, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, John Hopkins University, Baltimore, Maryland, USA
| | - Renee Stapleton
- Pulmonary and Critical Care, University of Vermont, Burlington, Vermont, USA
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16
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Weischendorff S, Kielsen K, Nederby M, Schmidt L, Burrin D, Heilmann C, Ifversen M, Sengeløv H, Mølgaard C, Müller K. Reduced Plasma Amino Acid Levels During Allogeneic Hematopoietic Stem Cell Transplantation Are Associated with Systemic Inflammation and Treatment-Related Complications. Biol Blood Marrow Transplant 2019; 25:1432-1440. [PMID: 30910606 DOI: 10.1016/j.bbmt.2019.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/15/2019] [Indexed: 12/26/2022]
Abstract
Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are challenged by cytotoxic effects of the conditioning regimen, resulting in tissue damage, systemic inflammation, and increased metabolic demands for amino acids to regenerate damaged tissues, reconstitute hematopoietic cells, and establish antioxidant defenses. To date, few studies have addressed the role of plasma amino acid (PAA) levels during transplantation, and it remains unknown if amino acid deficiency can aggravate treatment-related morbidity. We determined plasma levels of the 23 human amino acids in 80 HSCT recipients (age 1.1 to 55.4 years) before conditioning and on days +7 and +21 post-transplant along with C-reactive protein (CRP) and IL-6 levels on day +7. Significant changes were observed in plasma concentrations of several human amino acids during HSCT. On day +7, numerous amino acids were inversely correlated with both CRP and IL-6, including glutamic acid, serine, alanine, glutamine, arginine, cysteine, glycine, histidine, lysine, tryptophan, threonine, taurine, proline, and methionine (r = -.22 to -.66; all P < .05). Patients who developed sinusoidal obstruction syndrome (SOS) had significantly lower mean total PAA levels compared with patients without SOS (2013 ng/L [95% confidence interval (CI), 1709 to 2318 ng/L] versus 2706 ng/L [95% CI, 2261 to 3150 ng/L]; P = .006), along with lower individual levels of glutamic acid, serine, arginine, glycine, lysine, valine, tryptophan, threonine, and proline on day +7 (all P < .05). Patients with severe acute graft-versus-host disease had a lower mean total PAA level (1922 ng/L [95% CI, 1738 to 2106 ng/L] versus 2649 ng/L [95% CI, 2244 to 3055 ng/L]; P = .014) and lower levels of serine, glutamine, cysteine, glycine, lysine, and threonine on day +7 (all P < .05). These results indicate a relationship between low concentrations of certain amino acids and the risk of treatment-related complications.
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Affiliation(s)
- Sarah Weischendorff
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.
| | - Katrine Kielsen
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Maria Nederby
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Lotte Schmidt
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Douglas Burrin
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Carsten Heilmann
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Sengeløv
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark; Pediatric Nutrition Unit, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Müller
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Rigshospitalet, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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17
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Sharma K, Mogensen KM, Robinson MK. Pathophysiology of Critical Illness and Role of Nutrition. Nutr Clin Pract 2018; 34:12-22. [DOI: 10.1002/ncp.10232] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Kavita Sharma
- Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Kris M. Mogensen
- Department of Nutrition; Brigham and Women's Hospital; Boston Massachusetts USA
| | - Malcolm K. Robinson
- Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
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18
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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: 1305] [Impact Index Per Article: 217.5] [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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19
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Dickerson RN. Metabolic support challenges with obesity during critical illness. Nutrition 2018; 57:24-31. [PMID: 30153576 DOI: 10.1016/j.nut.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 12/21/2022]
Abstract
Adiposity-based chronic disease, critical illness, and nutrition therapy increase the risk for overfeeding and worsened nutritional and clinical outcomes. Hypocaloric, high-protein nutrition therapy provides critically ill obese patients the opportunity to achieve net protein anabolism with a reduced risk for overfeeding-related complications. The intent of this review is to discuss the impact of obesity on clinical outcomes, describe the consequences of obesity that increase complications associated with nutrition therapy, provide the framework to develop a hypocaloric, high-protein regimen, review the scientific evidence to support this mode of therapy, and discuss its limitations. Practical suggestions for patient monitoring are also provided.
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Affiliation(s)
- Roland N Dickerson
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
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20
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Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
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Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
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21
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Wolfe RR. The 2017 Sir David P Cuthbertson lecture. Amino acids and muscle protein metabolism in critical care. Clin Nutr 2017; 37:1093-1100. [PMID: 29291898 DOI: 10.1016/j.clnu.2017.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
Abstract
In this short review, our current understanding of key aspects of the catabolic response are presented in the context of the seminal contributions of Sir David Cuthbertson. Studies have confirmed that an increase in resting energy expenditure occurs in almost all forms of critical illness and injury. However, meeting the resulting increase in caloric requirement is not an insurmountable problem. The primary focus of nutritional support should be the net loss of body protein. Increased intake of dietary protein may ameliorate, but usually will not entirely reverse, the accelerated loss of body protein because of anabolic resistance. Anabolic resistance is due, at least in part, to impaired inward transport efficiency of amino acids from blood into muscle. Simultaneous consumption of excess non-protein calories in an anabolic resistant state provides minimal additional benefit, and may cause potentially adverse effects, including accumulation of liver fat and excess production of carbon dioxide. Because of the limited effectiveness of dietary protein and non-protein caloric intake, it is likely that traditional nutritional support alone will not reverse the net loss of body protein in the catabolic state. The reversal of the catabolic response can only be accomplished in many patients by combining reasonable nutritional support with appropriate metabolic control. Metabolic control may be achieved with the use of a number of pharmacological approaches, including propranolol, insulin or testosterone. Regardless of the approach, ensuring an adequate availability of dietary essential amino acids is necessary for pharmacologic therapy to result in an increased rate of protein synthesis.
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Affiliation(s)
- Robert R Wolfe
- University of Arkansas for Medical Sciences, Department of Geriatrics, 4301 West Markham Street, Slot 806, Little Rock, AR 72205-7199, USA.
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22
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Sundström Rehal M, Liebau F, Tjäder I, Norberg Å, Rooyackers O, Wernerman J. A supplemental intravenous amino acid infusion sustains a positive protein balance for 24 hours in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:298. [PMID: 29212550 PMCID: PMC5719794 DOI: 10.1186/s13054-017-1892-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 11/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Providing supplemental amino acids to ICU patients during a 3-h period results in improved whole-body net protein balance, without an increase in amino acid oxidation. The primary objective was to investigate if a 24-h intravenous amino acid infusion in critically ill patients has a sustained effect on whole-body protein balance as was seen after 3 h. Secondary objectives were monitoring of amino acid oxidation rate, urea and free amino acid plasma concentrations. METHODS An infusion of [1-13C]-phenylalanine was added to ongoing enteral nutrition to quantify the enteral uptake of amino acids. Primed intravenous infusions of [ring-2H5]-phenylalanine and [3,3-2H2]-tyrosine were used to assess whole-body protein synthesis and breakdown, to calculate net protein balance and to assess amino acid oxidation at baseline and at 3 and 24 hours. An intravenous amino acid infusion was added to nutrition at a rate of 1 g/kg/day and continued for 24 h. RESULTS Eight patients were studied. The amino acid infusion resulted in improved net protein balance over time, from -1.6 ± 7.9 μmol phe/kg/h at 0 h to 6.0 ± 8.8 at 3 h and 7.5 ± 5.1 at 24 h (p = 0.0016). The sum of free amino acids in plasma increased from 3.1 ± 0.6 mmol/L at 0 h to 3.2 ± 0.3 at 3 h and 3.6 ± 0.5 at 24 h (p = 0.038). Amino acid oxidation and plasma urea were not altered significantly. CONCLUSION We demonstrated that the improvement in whole-body net protein balance from a supplemental intravenous amino acid infusion seen after 3 h was sustained after 24 h in critically ill patients. TRIAL REGISTRATION This trial was prospectively registered at Australian New Zealand Clinical Trials Registry. ACTRN, 12615001314516 . Registered on 1 December 2015.
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Affiliation(s)
- Martin Sundström Rehal
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden. .,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden.
| | - Felix Liebau
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Inga Tjäder
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Åke Norberg
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan Wernerman
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital Huddinge, Stockholm, Sweden
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23
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Affiliation(s)
- Roland N. Dickerson
- University of Tennessee Health Science Center, 26 South Dunlap St., Rm 210, Memphis, TN 38163
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24
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Patkova A, Joskova V, Havel E, Kovarik M, Kucharova M, Zadak Z, Hronek M. Energy, Protein, Carbohydrate, and Lipid Intakes and Their Effects on Morbidity and Mortality in Critically Ill Adult Patients: A Systematic Review. Adv Nutr 2017; 8:624-634. [PMID: 28710148 PMCID: PMC5502871 DOI: 10.3945/an.117.015172] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The guidelines for nutritional support in critically ill adult patients differ in various aspects. The optimal amount of energy and nutritional substrates supplied is important for reducing morbidity and mortality, but unfortunately this is not well known, because the topic is complex and every patient is individual. The aim of this review was to gather recent pertinent information concerning the nutritional support of critically ill patients in the intensive care unit (ICU) with respect to the energy, protein, carbohydrate, and lipid intakes and the effect of their specific utilization on morbidity and mortality. Enteral nutrition (EN) is generally recommended over parenteral nutrition (PN) and is beneficial when administered within 24-48 h after ICU admission. In contrast, early PN does not provide substantial advantages in terms of morbidity and mortality, and the time when it is safe and beneficial remains unclear. The most advantageous recommendation seems to be administration of a hypocaloric (<20 kcal · kg-1 · d-1), high-protein diet (amino acids at doses of ≥2 g · kg-1 · d-1), at least during the first week of critical illness. Another important factor for reducing morbidity is the maintenance of blood glucose concentrations at 120-150 mg/dL, which is accomplished with the use of insulin and lower doses of glucose of 1-2 g · kg-1 · d-1, because this prevents the risk of hypoglycemia and is associated with a better prognosis according to recent studies. A fat emulsion is used as a source of required calories because of insulin resistance in the majority of patients. In addition, lipid oxidation in these patients is ∼25% higher than in healthy subjects.
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Affiliation(s)
- Anna Patkova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Vera Joskova
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Eduard Havel
- Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Miroslav Kovarik
- Departments of Biological and Medical Sciences and,Departments of Research and Development and
| | - Monika Kucharova
- Biophysics and Physical Chemistry, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic; and,Departments of Research and Development and
| | | | - Miloslav Hronek
- Departments of Biological and Medical Sciences and .,Departments of Research and Development and
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25
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Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
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Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1,Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
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26
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Dickerson RN, Patel JJ, McClain CJ. Protein and Calorie Requirements Associated With the Presence of Obesity. Nutr Clin Pract 2017; 32:86S-93S. [PMID: 28388369 DOI: 10.1177/0884533617691745] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Obesity compounds the metabolic response to critical illness and increases the risk for overfeeding complications due to its comorbidities. Hypocaloric, high-protein nutrition therapy affords the hospitalized patient with obesity the opportunity to achieve net protein anabolism with a reduced risk of overfeeding complications. The intent of this review is to provide the theoretical framework for development of a hypocaloric high-protein regimen, scientific evidence to support this mode of therapy, and unique considerations for its use in specialized subpopulations. Macronutrient goals and practical suggestions for patient monitoring are given.
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Affiliation(s)
- Roland N Dickerson
- 1 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Jayshil J Patel
- 2 Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 3 Departments of Medicine and Pharmacology & Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
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27
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Weijs PJM, Dickerson RN, Heyland DK, Moore FA, Rugeles SJ, McClave SA. Experimental and Outcome-Based Approaches to Protein Requirements in the Intensive Care Unit. Nutr Clin Pract 2017; 32:77S-85S. [PMID: 28388371 DOI: 10.1177/0884533617692774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.
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Affiliation(s)
- Peter J M Weijs
- 1 Nutrition and Dietetics, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.,2 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands.,3 Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, the Netherlands.,4 Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Roland N Dickerson
- 5 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Daren K Heyland
- 6 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,7 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Frederick A Moore
- 8 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Saúl J Rugeles
- 9 Department of Surgery, Pontificia Universidad Javeriana, Medical School, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Stephen A McClave
- 10 Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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28
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Dickerson RN, Mason DL, Croce MA, Minard G, Brown RO. Evaluation of an Artificial Neural Network to Predict Urea Nitrogen Appearance for Critically Ill Multiple-Trauma Patients. JPEN J Parenter Enteral Nutr 2017; 29:429-35. [PMID: 16224036 DOI: 10.1177/0148607105029006429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Computer-based simulated biologic neural network models have made significant strides in clinical medicine. METHODS To determine the predictive performance of a conventional regression model and an artificial neural network for estimating urea nitrogen appearance (UNA) during critical illness, 125 adult patients admitted to the trauma intensive care unit who required specialized nutrition support were studied. The first 100 consecutive patients were used to develop the 2 models. The first model used stepwise multivariate regression analysis. The second model entailed the use of a feeding-forward, back-propagation, supervised neural network. Bias and precision of both methods were evaluated in 25 separate patients. RESULTS Multivariate regression analysis revealed a significant highly correlative relationship (r(2) = .918, p < or = .01): Predicted UNA (g/d) = (0.29 x WT) + (1.20 x WBC) + (0.44 x SUN) with WT as current body weight in kg, WBC as white blood cell count in cells/mm(3), and SUN as serum urea nitrogen concentration (mg/dL). The regression method was biased toward overestimating measured UNA, whereas the neural network was unbiased. Precision (95% confidence interval) of the neural network was significantly better than the regression (3.3-7.2 g vs 7.3-11.6 g, respectively, p < .01). Regression analysis successfully predicted UNA within 3 g of measured UNA in 16% (4 of 25) of patients, whereas the neural network successfully predicted UNA in 44% (11 out of 25) of patients (p < .06). CONCLUSIONS These preliminary data indicate that use of an artificial neural network may be superior to conventional regression modeling techniques for estimating UNA in critically ill adult multiple-trauma patients receiving specialized nutrition support.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, 38163, USA.
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29
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Abstract
Traumatic injury induces hypermetabolism. The degree of hypermetabolism can be variable, depending on the type of injury, the degree of inflammation, body composition, age, and treatment regimens. To estimate metabolic rate in some types of injury, predictive equations have been published. Some of these equations have been tested in validation studies. For other types of injury, equations do not exist. Some expert panels have recommended measuring in lieu of estimating metabolic rate, though studies have not been performed to determine whether clinical outcome is affected by the method used to determine energy requirements. Traumatically injured patients are usually catabolic, but protein needs after traumatic injury continue to be debated. Some suggest that 1.5 g protein per kg body weight is adequate and that any additional protein is simply oxidized, adding to the nitrogen load to be excreted. Alternately, protein intake >2.0 g/kg body weight increases the absolute rate of body protein synthesis, and achievement of nitrogen balance has been associated with survival. Thus, provision of high-protein feeding to achieve nitrogen balance might be worthwhile, even if that balance is achieved at the cost of additional nitrogen production.
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Affiliation(s)
- David Frankenfield
- Department of Clinical Nutrition, Penn State's Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA.
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30
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Abstract
During critical illness, the stress response causes accelerated gluconeogenesis and lipolysis, leading to hyperglycemia and elevated serum triglyceride levels. The traditional nutrition support strategy of meeting or exceeding calorie requirements may compound the metabolic alterations of the stress response. Hypocaloric nutrition support has the potential to provide nutrition support without exacerbating the stress response. Studies have shown hypocaloric nutrition support to be safe and to achieve nitrogen balance comparable with traditional regimens. Benefits shown include improved glycemic control, decreased intensive care unit (ICU) length of stay (LOS), and decreased ventilator days and infection rate; however, not all studies have produced identical results. Providing adequate dietary protein has emerged as an important factor in efficacy of the hypocaloric regimen. Although it is inconclusive, currently available research suggests that a nutrition support goal of 10-20 kcal/kg of ideal or adjusted weight and 1.5-2 g/kg ideal weight of protein may be beneficial during the acute stress response. Well-designed, randomized, controlled studies with adequate sample size that evaluate relevant clinical outcomes such as mortality, ICU LOS, and infection while controlling for factors such as glycemic control, severity of illness, incorporation of calories from all sources, in addition to feeding regimens, are needed to definitively determine the effects of hypocaloric nutrition support.
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Affiliation(s)
- Megan Boitano
- Clinical Nutrition, Scripps Memorial Hospital-Encinitas, ENC14, Encinitas, CA 92024, USA.
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31
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Abstract
Critically ill people are unable to eat. What’s the best way to feed them? Nutrition authorities have long recommended providing generous amounts of protein and calories to critically ill patients, either intravenously or through feeding tubes, in order to counteract the catabolic state associated with this condition. In practice, however, patients in modern intensive care units are substantially underfed. Several large randomized clinical trials were recently carried out to determine the clinical implications of this situation. Contradicting decades of physiological, clinical, and observational data, the results of these trials have been claimed to justify the current practice of systematic underfeeding in the intensive care unit. This article explains and suggests how to resolve this conundrum.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Bruce R Bistrian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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32
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients. ACTA ACUST UNITED AC 2016. [DOI: 10.3918/jsicm.23.185] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Oshima T, Deutz NE, Doig G, Wischmeyer PE, Pichard C. Protein-energy nutrition in the ICU is the power couple: A hypothesis forming analysis. Clin Nutr 2015; 35:968-74. [PMID: 26608526 DOI: 10.1016/j.clnu.2015.10.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 10/06/2015] [Accepted: 10/27/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS We hypothesize that an optimal and simultaneous provision of energy and protein is favorable to clinical outcome of the critically ill patients. METHODS We conducted a review of the literature, obtained via electronic databases and focused on the metabolic alterations during critical illness, the estimation of energy and protein requirements, as well as the impact of their administration. RESULTS Critically ill patients undergo severe metabolic stress during which time a great amount of energy and protein is utilized in a variety of reactions essential for survival. Energy provision for critically ill patients has drawn attention given its association with morbidity, survival and long-term recovery, but protein provision is not sufficiently taken into account as a critical component of nutrition support that influences clinical outcome. Measurement of energy expenditure is done by indirect calorimetry, but protein status cannot be measured with a bedside technology at present. CONCLUSIONS Recent studies suggest the importance of optimal and combined provision of energy and protein to optimize clinical outcome. Clinical randomized controlled studies measuring energy and protein targets should confirm this hypothesis and therefore establish energy and protein as a power couple.
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Affiliation(s)
- Taku Oshima
- Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana Chuou-ku, Chiba City, Chiba 260-8677, Japan.
| | - Nicolaas E Deutz
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, Texas, USA.
| | - Gordon Doig
- Royal North Shore Hospital, Northern Clinical School Intensive Care Research Unit, University of Sydney, Sydney, Australia.
| | - Paul E Wischmeyer
- Department of Anesthesiology, University of Colorado School of Medicine, 12700 E, 19th Avenue, Box 8602, RC2 P15-7120, Aurora, CO 80045, USA.
| | - Claude Pichard
- Clinical Nutrition, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
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Abstract
Patients with advanced heart failure and poor nutritional status are predisposed to higher rates of infection, bleeding, and mortality. We have increasingly used perioperative parenteral nutrition (PN) in ventricular assist device (VAD) patients and now report our initial experience. We performed a retrospective review of 43 consecutive patients who received implantable VADs from 2006 to 2009. We compared outcomes for patients receiving PN for >7 days perioperatively vs ≤7 days. In addition, we compared patients who received preoperative enteral nutrition (EN) with those who did not. Fourteen patients received perioperative PN in addition to EN for >7 days compared with 29 patients who received either PN for ≤7 days or EN alone. Univariate analysis showed no differences in infection, bleeding, thrombus, stroke, length of stay, or mortality. Multivariate stepwise regression including EN, preoperative PN, Interagency Registry for Mechanically Assisted Circulation score, age, gender, and VAD indication showed that only EN was associated with infection. Prolonged use of perioperative PN appears to be safe and well tolerated in patients undergoing VAD implantation. Preoperative EN, while increasing infection risk, seems to have no harmful effect on survival.
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36
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Nicolo M, Heyland DK, Chittams J, Sammarco T, Compher C. Clinical Outcomes Related to Protein Delivery in a Critically Ill Population: A Multicenter, Multinational Observation Study. JPEN J Parenter Enteral Nutr 2015; 40:45-51. [PMID: 25900319 DOI: 10.1177/0148607115583675] [Citation(s) in RCA: 186] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/20/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Optimal intake of energy and protein is associated with improved outcomes, although outcomes relative to protein intake are very limited. Our purpose was to evaluate the impact of prescribed protein delivery on mortality and time to discharge alive (TDA) using data from the International Nutrition Survey 2013. We hypothesized that greater protein delivery would be associated with lower mortality and shorter TDA. METHODS The sample included patients in the intensive care unit (ICU) ≥ 4 days (n = 2828) and a subsample in the ICU ≥ 12 days (n = 1584). Models were adjusted for evaluable nutrition days, age, body mass index, sex, admission type, acuity scores, and geographic region. Percentages of prescribed protein and energy intake were compared with mortality outcomes using logistic regression and with Cox proportional hazards for TDA. RESULTS Mean intake for the 4-day sample was protein 51 g (60.5% of prescribed) and 1100 kcal (64.1% of prescribed); for the 12-day sample, mean intake was protein 57 g (66.7% of prescribed) and 1200 kcal (70.7% of prescribed). Achieving ≥ 80% of prescribed protein intake was associated with reduced mortality (4-day sample: odds ratio [OR], 0.68; 95% confidence interval [CI], 0.50-0.91; 12-day sample: OR, 0.60; 95% CI, 0.39-0.93), but ≥ 80% of prescribed energy intake was not. TDA was shorter with ≥ 80% prescribed protein (hazard ratio [HR], 1.25; 95% CI, 1.04-1.49) in the 12-day sample but longer with ≥ 80% prescribed energy in the 4-day sample (HR, 0.82; 95% CI, 0.69-0.96). CONCLUSION Achieving at least 80% of prescribed protein intake may be important to survival and shorter TDA in ICU patients. Efforts to achieve prescribed protein intake should be maximized.
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Affiliation(s)
- Michele Nicolo
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daren K Heyland
- Department of Medicine, Clinical Evaluation Research Unit, Kingston General Hospital, Ontario, Canada
| | - Jesse Chittams
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Therese Sammarco
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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37
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Cunha HFRD, Rocha EEMD, Hissa M. Protein requirements, morbidity and mortality in critically ill patients: fundamentals and applications. Rev Bras Ter Intensiva 2015; 25:49-55. [PMID: 23887760 PMCID: PMC4031858 DOI: 10.1590/s0103-507x2013000100010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/25/2013] [Indexed: 12/07/2022] Open
Abstract
Recent evidence suggests that a negative protein balance secondary to severe disease is associated with increased morbidity. A loss of total body protein is inevitable in this scenario, even with an aggressive nutritional approach, primarily due to the catabolism of skeletal muscle fibers. The ubiquitin-proteasome system is the primary metabolic and biochemical mechanism involved in this process; paradoxically, this system consumes adenosine triphosphate as its energy source. It is possible that a neutral protein balance in these clinical situations is important for improving outcomes and achieving the caloric goals estimated or measured by indirect calorimetry. Recent studies have suggested that the use of higher protein concentrations in nutritional therapy for critically ill patients may help to reduce mortality. The purpose of this study was to review some of the nutrition therapy principles related to protein metabolism, evaluate the main assertions of the guidelines of specialty societies and review the recent studies that address these issues using critical insights from the authors' clinical experience.
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Feinberg J, Nielsen EE, Gluud C, Lindschou J, Kondrup J, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Braunschweig CA, Sheean PM, Peterson SJ, Gomez Perez S, Freels S, Troy KL, Ajanaku FC, Patel A, Sclamberg JS, Wang Z. Exploitation of diagnostic computed tomography scans to assess the impact of nutrition support on body composition changes in respiratory failure patients. JPEN J Parenter Enteral Nutr 2014; 38:880-5. [PMID: 23976767 PMCID: PMC3947493 DOI: 10.1177/0148607113500505] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Assessment of nutritional status in intensive care unit (ICU) patients is limited. Computed tomography (CT) scans that include the first to fifth lumbar region completed for diagnostic purposes measures fat and lean body mass (LBM) depots and are frequently done in ICU populations and can be used to quantify fat and LBM depots. The purpose of this study was to assess if these scans could measure change in skeletal muscle (SKT), visceral adipose (VAT), and intermuscular adipose (IMAT) tissue and to examine the association between the amount of energy and protein received and changes in these depots. METHODS Cross-sectional area of SKT, VAT, and IMAT from CT scans at the third lumbar region was quantified at 2 time points (CT1 and CT2). Change scores between CT1 and CT2 for each of these depots and the percentage of estimated energy/protein needs received were determined in 33 adults that with acute respiratory failure. Descriptive statistics and multiple regression was used to evaluate the influence of baseline characteristics and the percentage energy/protein needs received between CT1 and CT2 on percentage change/day between CT1 and CT2 on SKM, IMAT, and VAT. RESULTS Participants were on average (SD) 59.7 (16) years old, received 41% of energy and 57% of protein needs. The average time between CT1 and CT2 was 10 (5) days. SKM declined 0.49%/day (men P = .07, women P = .09) and percentage of energy needs received reduced loss (β = 0.024, P = .03). No change in VAT or IMAT occurred. CONCLUSIONS CT scans can be exploited to assess change in body composition in ICU patients and may assist in detecting the causal link between nutritional support and outcomes in future clinical trials.
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Affiliation(s)
- Carol A Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, IL, USA
| | - Patricia M Sheean
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Sarah J Peterson
- Department of Food and Nutrition, Rush University Medical Center, Chicago, IL, USA
| | - Sandra Gomez Perez
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Sally Freels
- Department of Epidemiology and Biostatitics, University of Illinois at Chicago, Chicago IL, USA
| | - Karen L Troy
- Department of Biomedical Engineering Worcester Polytechnic Institute, 100 Institute Rd, Worcester, MA 01609
| | | | - Ankur Patel
- Department of Radiology and Nuclear Medicine, Rush University Medical Center, Chicago IL, USA
| | - Joy S Sclamberg
- Department of Radiology and Nuclear Medicine, Rush University Medical Center, Chicago IL, USA
| | - Zebin Wang
- AstraZeneca Pharmaceuticals, Waltham, MA, USA
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The Effect of Nutritional Status in the Pathogenesis of Critical Illness Myopathy (CIM). BIOLOGY 2014; 3:368-82. [PMID: 24887774 PMCID: PMC4085613 DOI: 10.3390/biology3020368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 05/22/2014] [Accepted: 05/27/2014] [Indexed: 12/23/2022]
Abstract
The muscle wasting and loss of specific force associated with Critical Illness Myopathy (CIM) is, at least in part, due to a preferential loss of the molecular motor protein myosin. This acquired myopathy is common in critically ill immobilized and mechanically ventilated intensive care patients (ICU). There is a growing understanding of the mechanisms underlying CIM, but the role of nutritional factors triggering this serious complication of modern intensive care remains unknown. This study aims at establishing the effect of nutritional status in the pathogenesis of CIM. An experimental ICU model was used where animals are mechanically ventilated, pharmacologically paralysed post-synaptically and extensively monitored for up to 14 days. Due to the complexity of the experimental model, the number of animals included is small. After exposure to this ICU condition, animals develop a phenotype similar to patients with CIM. The results from this study show that the preferential myosin loss, decline in specific force and muscle fiber atrophy did not differ between low vs. eucaloric animals. In both experimental groups, passive mechanical loading had a sparing effect of muscle weight independent on nutritional status. Thus, this study confirms the strong impact of the mechanical silencing associated with the ICU condition in triggering CIM, overriding any potential effects of caloric intake in triggering CIM. In addition, the positive effects of passive mechanical loading on muscle fiber size and force generating capacity was not affected by the nutritional status in this study. However, due to the small sample size these pilot results need to be validated in a larger cohort.
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Lefrant JY, Hurel D, Cano N, Ichai C, Preiser JC, Tamion F. Nutrition artificielle en réanimation. NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Braunschweig CA, Sheean PM, Peterson SJ, Gomez Perez S, Freels S, Lateef O, Gurka D, Fantuzzi G. Intensive nutrition in acute lung injury: a clinical trial (INTACT). JPEN J Parenter Enteral Nutr 2014; 39:13-20. [PMID: 24722769 DOI: 10.1177/0148607114528541] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite extensive use of enteral (EN) and parenteral nutrition (PN) in intensive care unit (ICU) populations for 4 decades, evidence to support their efficacy is extremely limited. METHODS A prospective randomized trial was conducted evaluate the impact on outcomes of intensive medical nutrition therapy (IMNT; provision of >75% of estimated energy and protein needs per day via EN and adequate oral diet) from diagnosis of acute lung injury (ALI) to hospital discharge compared with standard nutrition support care (SNSC; standard EN and ad lib feeding). The primary outcome was infections; secondary outcomes included number of days on mechanical ventilation, in the ICU, and in the hospital and mortality. RESULTS Overall, 78 patients (40 IMNT and 38 SNSC) were recruited. No significant differences between groups for age, body mass index, disease severity, white blood cell count, glucose, C-reactive protein, energy or protein needs occurred. The IMNT group received significantly higher percentage of estimated energy (84.7% vs 55.4%, P < .0001) and protein needs (76.1 vs 54.4%, P < .0001) per day compared with SNSC. No differences occurred in length of mechanical ventilation, hospital or ICU stay, or infections. The trial was stopped early because of significantly greater hospital mortality in IMNT vs SNSC (40% vs 16%, P = .02). Cox proportional hazards models indicated the hazard of death in the IMNT group was 5.67 times higher (P = .001) than in the SNSC group. CONCLUSIONS Provision of IMNT from ALI diagnosis to hospital discharge increases mortality.
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Affiliation(s)
- Carol A Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Sarah J Peterson
- Department of Food and Nutrition, Rush University Medical Center, Chicago, Illinois, USA
| | - Sandra Gomez Perez
- Institute for Health Policy and Research, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sally Freels
- Department of Epidemiology and Biostatitics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Omar Lateef
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - David Gurka
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Giamila Fantuzzi
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
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Petros S, Horbach M, Seidel F, Weidhase L. Hypocaloric vs Normocaloric Nutrition in Critically Ill Patients: A Prospective Randomized Pilot Trial. JPEN J Parenter Enteral Nutr 2014; 40:242-9. [PMID: 24699555 DOI: 10.1177/0148607114528980] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 03/02/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Optimal nutrition of critically ill patients is still a matter of debate. This pilot trial aimed to compare the impact of normocaloric vs hypocaloric feeding in critically ill patients in the first 7 days in the intensive care unit (ICU). The primary end point was the rate of nosocomial infections during the ICU stay. METHODS Critically ill patients requiring artificial nutrition for at least 72 hours were included within 24 hours of ICU admission and randomized into a normocaloric group (receiving 100% of their daily energy expenditure) and a hypocaloric group (receiving 50% of their daily energy expenditure). RESULTS One hundred patients were included (54 in the normocaloric group and 46 in the hypocaloric group). There were 66 male and 34 female patients with a mean age of 65.8 ± 11.6 years. The mean daily caloric supply was 19.7 ± 5.7 kcal/kg for the normocaloric group and 11.3 ± 3.1 kcal/kg for the hypocaloric group (P = .0001). Insulin demand was significantly higher and gastrointestinal intolerance more frequent in the normocaloric group than in the hypocaloric group. Nosocomial infections were detected more frequently in the hypocaloric group than in the normocaloric group (26.1% vs 11.1%, respectively). The ICU mortality rate was 22.2% in the normocaloric group and 21.7% in the hypocaloric group (not significant). The hospital mortality rate was 31.5% in the normocaloric group and 37.0% in the hypocaloric group (P = .67). CONCLUSION Hypocaloric feeding in the first 7 days in critically ill patients was associated with more nosocomial infections but less insulin demand and less gastrointestinal intolerance compared with normocaloric feeding. TRIAL REGISTRATION NUMBER DRKS00000104 (German Clinical Trials Register).
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Affiliation(s)
- Sirak Petros
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Monika Horbach
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Frank Seidel
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
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Hartl WH, Jauch KW. Metabolic self-destruction in critically ill patients: Origins, mechanisms and therapeutic principles. Nutrition 2014; 30:261-7. [DOI: 10.1016/j.nut.2013.07.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/19/2013] [Accepted: 07/20/2013] [Indexed: 01/08/2023]
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Lefrant JY, Hurel D, Cano NJ, Ichai C, Preiser JC, Tamion F. [Guidelines for nutrition support in critically ill patient]. ACTA ACUST UNITED AC 2014; 33:202-18. [PMID: 24565944 DOI: 10.1016/j.annfar.2014.01.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J-Y Lefrant
- Services des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hurel
- Service de réanimation médico-chirurgicale, centre hospitalier François-Quesnay, 2, boulevard Sully, 78201 Mantes-la-Jolie cedex, France
| | - N J Cano
- Service de nutrition, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand cedex, France; Unité de nutrition humaine, Clermont université, université d'Auvergne, BP 10448, 63000 Clermont-Ferrand, France; Inra, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - C Ichai
- Service de réanimation médico-chirurgicale, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06006 Nice cedex 1, France
| | - J-C Preiser
- Service des soins intensifs, hôpital universitaire Erasme, 808, route de Lennik, 1070 Bruxelles, Belgique
| | - F Tamion
- Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76081 Rouen cedex, France
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Lawson CM, Daley BJ, Sams VG, Martindale R, Kudsk KA, Miller KR. Factors That Impact Patient Outcome. JPEN J Parenter Enteral Nutr 2013; 37:30S-8S. [DOI: 10.1177/0148607113499372] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Christy M. Lawson
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Valerie G. Sams
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Robert Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Kenneth A. Kudsk
- Veteran Administration Surgical Service, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Keith R. Miller
- Department of Surgery, University of Louisville, Louisville, Kentucky
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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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Disease-specific nutrition therapy: one size does not fit all. Eur J Trauma Emerg Surg 2013; 39:215-33. [PMID: 26815228 DOI: 10.1007/s00068-013-0264-8] [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] [Received: 10/24/2012] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states. METHODS A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients. RESULTS Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients. CONCLUSION There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.
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