Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications--a randomized clinical trial

The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

Applying the 2022 ASPEN adult nutrition support guidelines in a 2024 ICU

An update to the American Society for Parenteral and Enteral Nutrition guidelines for nutrition provision in critically ill adults was published in 2022. In contrast to the previous set of guidelines published in 2016, the revised guidelines selected only studies meeting specific criteria for scientific rigor and only considered publications reflecting more modern intensive care unit (ICU) practices (studies between January 1, 2001, and July 15, 2020). No consensus recommendations were included. Although these methods limited the number of recommendations made and the applicability to current ICU practices, important implications for patient care were evaluated and acknowledged. The literature supporting guideline recommendations that impact parenteral nutrition management is summarized in this review, along with key studies published after the guidelines were revised. Considerations for practical application of this evidence, along with limitations and future guideline directions, are also described.

Optimal energy provision early in ICU stay for critically ill patients receiving parenteral nutrition

BACKGROUND

Literature on optimal energy provision via parenteral nutrition (PN) is limited and the evidence quality is low. The purpose of this study is to determine if there is a difference in outcomes in adult critically ill patients when receiving lower vs higher calorie provision via PN early in intensive care unit (ICU) stay.

METHODS

Adult patients initiated on PN within the first 10 days of ICU stay from May 2014 to June 2021 were included in this retrospective study. The primary outcome was to determine the impact of lower (<20 kcal/kg/day) vs higher (>25 kcal/kg/day) calorie provision on all-cause, in-hospital mortality. Secondary outcomes were to determine the impact of calorie provision on hospital or ICU length of stay and incidence of complications.

RESULTS

This study included 133 patients: a lower calorie provision group (n = 77) and a higher calorie provision group (n = 56). There was a significant difference in all-cause, in-hospital mortality between the lower and the higher calorie provision groups (36.36% and 17.86%, respectively; P = 0.02). However, upon a multivariate analysis of death at discharge, the specific calorie provision group did not affect the probability of death at hospital discharge. The secondary outcomes were not significantly different between groups.

CONCLUSION

When comparing lower calorie provision with higher calorie provision in adult critically ill patients receiving PN early within their ICU stay, there were no differences in outcomes after controlling for significant confounders. Future larger prospective studies should further evaluate optimal caloric provision via PN in this population.

Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis

BACKGROUND

Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU).

METHODS

Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed.

RESULTS

Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%).

CONCLUSIONS

Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.

Burn Patient Metabolism and Nutrition

Following severe burns, patients have unique metabolic derangements that make adequate nutritional support imperative for their survival and recovery. Patients with burns have persistent and prolonged hypermetabolic states that lead to increased catabolism following injury. During rehabilitation, catabolism leads to increased muscle wasting and cachexia. Failure to adequately meet the patient's increased nutritional requirements can lead to poor wound healing, increased infections, and overall organ dysfunction. Because of these risks, adequate assessment and provision of nutritional needs are imperative to care for these patients.

Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Glycemic Management of Hospitalized Patients Receiving Nutrition Support

Enteral nutrition (EN) and parenteral nutrition (PN) increase the risk of hyperglycemia and adverse outcomes, including mortality, in patients with and without diabetes. A blood glucose target range of 140-180 mg/dL is recommended for hospitalized patients receiving artificial nutrition. Using a diabetes-specific EN formula, lowering the dextrose content, and using a hypocaloric PN formula have all been shown to prevent hyperglycemia and associated adverse outcomes. Insulin, given either subcutaneously or as a continuous infusion, is the mainstay of treatment for hyperglycemia. However, no subcutaneous insulin regimen has been shown to be superior to others. This review summarizes the evidence on and provides recommendations for the treatment of EN- and PN-associated hyperglycemia and offers strategies for hypoglycemia prevention. The authors also highlight their institution's protocol for the safe use of insulin in the PN bag. Randomized controlled trials evaluating safety and efficacy of targeted insulin therapy synchronized with different types of EN or PN delivery are needed.

Lipid-Enriched Parenteral Nutrition and Bloodstream Infections in Hospitalized Patients: Is It a Real Concern?

Today, few clinicians are still convinced that lipids are sepsis risk factors in patients receiving parenteral nutrition. This dogma is principally based on old literature. This review deals with the most recent literature search that provided up-to-date data over the past ten years. Systematic research was performed on Pubmed, MEDLINE, and Web of Science. The recent evidence does not justify the exclusion of lipid emulsions in patients receiving parenteral nutrition for fear of bloodstream infection risk. Moreover, lipids represent a substantial proportion of the energy source providing essential fatty acids, potentially improving clinical outcomes in patients often malnourished. Understanding the actual risk factors of sepsis during parenteral nutrition is necessary to optimize patient nutritional status and care and avoid essential fatty acid deficiency. There is an urgent need to make updated nutrition training available at all levels of medical education.

The goldilocks problem: Nutrition and its impact on glycaemic control

BACKGROUND

Glucose intolerance and insulin resistance manifest as hyperglycaemia in intensive care, which is associated with mortality and morbidities. Glycaemic control (GC) may improve outcomes, though safe and effective control has proven elusive. Nutritional glucose intake affects blood glucose (BG) outcomes, but few protocols actively control it. This study aims to examine BG outcomes in the context of nutritional management during GC.

METHODS

Retrospective cohort analysis of 5 glycaemic control cohorts spanning 4 years (n = 273) from Christchurch Hospital Intensive Care Unit (ICU). GC is delivered using a single model-based protocol (STAR), with default 4.4-8.0 mmol/L target range via. modulation of insulin and nutrition. Clinical adaptations/cohorts include variations on upper target (UL-9 with 9.0 mmol/L, reducing workload and nutrition responsiveness), and insulin only (IO) with clinically set nutrition at 3 glucose concentrations (71 g/L vs. 120 and 180 g/L in the TARGET study).

RESULTS

Percent of BG hours in the 4.4-8.0 mmol/L range highest under standard STAR conditions (78%), and was lower at 64% under UL-9, likely due to reduced time-responsiveness of nutrition-insulin changes. By comparison, IO only resulted in 64-69% BG in range across different nutrition types. A subset of patients receiving high glucose nutrition under IO were persistently hyperglycaemic, indicating patient-specific glucose tolerance.

CONCLUSION

STAR GC is most effective when nutrition and insulin are modulated together with timely responsiveness to persistent hyperglycaemia. Results imply modulation of nutrition alongside insulin improves GC, particularly in patients with persistent hyperglycaemia/low glucose tolerance.

Effect of high-protein nutrition in critically ill patients: A retrospective cohort study

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.

Hypoenergetic feeding does not improve outcomes in critically ill patients with premorbid obesity: a post hoc analysis of a randomized controlled trial

Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, there has been little data comparing feeding regimens for obese and non-obese critically ill surgical patients and the effect on outcomes. The objective was to compare the effect of hypoenergetic and euenergetic feeding goals in critically ill obese patients on outcomes, including infection, intensive care unit length of stay, and mortality. We hypothesized that hypoenergetic feeding of patients with premorbid obesity (body mass index ≥ 30 kg•m^-2) during critical illness does not affect clinical outcomes. Post hoc analyses were performed on critically ill surgical patients enrolled in a randomized controlled trial. Patients were randomized to receive 25-30 kcal•kg^-1•d^-1 (105-126 kJ.kg^-1•d^-1, euenergetic) or 12.5-15 kcal•kg^-1•d^-1 (52-63 kJ.kg^-1 •d^-1, hypoenergetic), with equal protein allocation (1.5 g•kg^-1•d^-1). The effect of feeding regimen on outcomes in obese and nonobese patients were assessed. Of the 83 patients, 30 (36.1%) were obese (body mass index ≥ 30 kg•m^-2). Average energy intake differed based on feeding regimen (hypoenergetic: 982±61 vs euenergetic: 1338±92 kcal•d^-1, P = .02). Comparing obese and nonobese patients, there was no difference in the percentage acquiring an infection (66.7% [20/30] vs 77.4% [41/53], P = .29), intensive care unit length of stay (16.4±3.7 vs 14.3±0.9 days, P = .39), or mortality (10% [3/30] vs 7.6% [4/53], P = .7). Within the subset of obese patients, the percentage acquiring an infection (hypoenergetic: 78.9% [15/19] vs euenergetic: 45.5% [5/11], P = .11) was not affected by the feeding regimen. Within the subset of nonobese patients, there was a trend toward more infections in the euenergetic group (hypoenergetic: 63.6% [14/22] vs euenergetic: 87.1% [27/31], P = .05). Hypoenergetic feeding does not appear to affect clinical outcomes positively or negatively in critically ill patients with premorbid obesity.

Impact of the Time to Initiation of Parenteral Nutrition on Patient Outcomes in Critically Ill Adults

Background:

The optimal time to initiate parenteral nutrition (PN) in critically ill adults in whom enteral nutrition is not feasible is controversial.

Objective:

The objectives were to compare in-hospital mortality and hospital length of stay in patients initiated on PN within 7 days or after 7 days of poor nutrient intake.

Methods:

This single-center, retrospective study included critically ill adult patients who received at least 2 consecutive days of PN during hospitalization from May 2014 to July 2016.

Results:

The median duration of PN (interquartile range) was 8 (5-13) days. In total, 110 patients received PN within 7 days of poor nutrient intake while 49 patients received PN after 7 days of poor nutrient intake. There was no statistically significant difference in in-hospital mortality between groups (29.09% vs 18.37%, P = .1535). Patients initiated within 7 days had a significantly shorter median hospital length of stay than patients initiated after 7 days (20 days vs 27 days, P = .0013). There were 69 patients who were classified as obese. Obese patients initiated within 7 days had a significantly shorter median hospital length of stay than obese patients initiated after 7 days (17 days vs 33 days, P = .0007).

Conclusions:

Time to initiation of PN did not impact in-hospital mortality. However, there was an association between early initiation of PN and a shorter hospital length of stay that was most pronounced among obese patients.

Perioperative Artificial Enteral Nutrition in Malnourished Esophageal and Stomach Cancer Patients and Its Impact on Postoperative Complications

Cancer is responsible for approximately 13% of all causes of death worldwide, and 20% of cancer patients die because of malnutrition and its complications. Malnutrition is common in cancer of stomach and esophagus. Although it is widely accepted that malnutrition adversely affects the postoperative outcome of patients, there is little evidence that perioperative nutrition support can reduce surgical risk in malnourished cancer patients. This prospective study was carried out from December 2016 to July 2017 at the Kidwai Memorial Institute of Oncology, Bengaluru. After stratified for age, sex, and tumor localization, patients were selected non-randomly and assigned to study (n = 30, 14 women, 16 men) and control group (n = 30, 14 women, 16 men) as alternate patients. Within 48 h of admission, patients underwent nutritional assessment by the subjective global assessment. Perioperative nutrition was administered in the study group by enteral route only. Patients had a functioning gastrointestinal tract, and they received enteral nutrition (EN). Target intake of non-protein (25 kcal/kg per day) and protein (0.25 g nitrogen/kg per day) was provided using available enteral formulas. This was supplementary to standard hospital diet. Nutritional re-assessment after 15 days of intervention showed significant change in nutritional status, which was measured as gain in weight for each patient. There were significant differences in the mortality and complications between the two groups. The total length of hospitalization and postoperative stay of the control patients were significantly longer than those of the study patients. In conclusion, perioperative nutrition support can decrease the incidence of postoperative complications in moderately and severely malnourished gastric and esophageal cancer patients. In addition, it is effective in reducing mortality. Enteral nutrition support alone can be used in the management of malnourished patients undergoing gastric and esophageal surgery.

The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

Extent and Predictors of Poor Glycaemic Control among Elderly Pakistani Patients with Type 2 Diabetes Mellitus: A Multi-Centre Cross-Sectional Study

Objectives: This study aimed to explore the relationship between glycaemic control and factors that may influence this among elderly type 2 diabetes mellitus (T2DM) patients in Lahore, Pakistan. Methods: This descriptive, cross-sectional study was conducted at the Jinnah and Sir Ganga Ram Hospitals, Lahore using convenience sampling techniques between 1 December 2015 and 28 February 2016. The sample consisted of elderly (>65 years) T2DM patients. Glycaemic values and patient characteristics were obtained from medical charts. Consenting patients were interviewed to complete the Barthel Index, Lawton Instrumental Activities of Daily Living Scale, Clinical Frailty Scale, Iowa Pain Thermometer Scale, Geriatric Depression Scale, Montreal Cognitive Assessment tool, Mini Nutritional Assessment Scale—Short Form and Self Care Inventory—Revised Version. Multiple logistic regression analysis was carried out to determine the predictors of poor glycaemic control. Results: A total of 490 patients were approached and 400 agreed to participate. Overall, nearly one-third (32.2%, n = 129) of patients had glycated haemoglobin (HbA1c) at the target level. Fasting and random plasma glucose levels were within the target range to much the same extent; (36.8%, n = 147) and (27%, n = 108), respectively. HbA1c levels were also higher in patients with co-morbidities (67.4%, n = 229) with diabetes-related complications (73.5%, n = 227). Significant predictors of impaired glycaemic control (HbA1c) included poor diabetes self-care (adjusted odds ratio (AOR) 0.96; 95% confidence interval (CI) 0.95, 0.98), not being prescribed oral hypoglycaemic agents (OHA) (AOR 6.22; 95% CI 2.09, 18.46), regular hypoglycaemic attacks (AOR 2.53; 95% CI 1.34, 4.81) and falling tendency (AOR 0.19; 95% CI 0.10, 0.36). Conclusions: Poor glycaemic control prevailed among the majority of elderly Pakistani diabetic patients in this study. Triggering factors of poor glycaemic control should be taken into consideration by the healthcare professionals in targeting multifaceted interventions to achieve good glycaemic control.

Controversies in the Use of Lipid Injectable Emulsion in Hospitalized Patients

Soybean oil-based lipid injectable emulsion (SO-based ILE) is an 18-carbon, ω-6 macronutrient providing a concentrated source of calories, which can be administered in or with parenteral nutrition to patients unable to tolerate or consume adequate enteral nutrition. Beyond the provision of energy, SO-based ILE provides linoleic and linolenic acid, 2 essential fatty acids necessary for the prevention of essential fatty acid deficiency. However, SO-based ILE with its high levels of ω-6 fatty acids, long-chain triglycerides, phospholipid emulsifiers, and glycerin has been associated with worsening clinical outcomes, including increase of infections, lengthier intensive care and hospital stay, and prolonged mechanical ventilation. Recognizing this, studies have investigated omitting SO-based ILE in the critically ill patient for the first 7 days to observe if clinical outcomes are improved. Unfortunately, there is extremely limited research, and what is available is controversial. National guidelines have analyzed the studies, and they too are challenged to define a clear, high quality of evidence recommendation. It is important for the healthcare clinician to understand the research around this controversy to make best decisions for their patients.

Prescribed hypocaloric nutrition support for critically-ill adults

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.

Nutrition therapy: A new criterion for treatment of patients in diverse clinical and metabolic situations

OBJECTIVE

This study developed an instrument in table format to help determine the energy requirements of patients in adverse situations. The instrument allows for the weekly adjustment of nutrition therapy and energy intake, advocating a new approach to treatment based on clinical observation performed by staff specialized in individualized nutrition therapy.

METHODS

The table was elaborated by grouping patients according to the following criteria: criticality, chronicity, and stability of the clinical status. Energy supply was readjusted weekly to respect the cyclicity of the patient's metabolic response.

RESULTS

The table should be used in the following order: Obese > Elderly > Specific Clinical Situations > Chronic Diseases > Stable Clinical Situations. The protein requirements of patients with pressure ulcers or with wounds healing by secondary intention should be increased by 30% to 50%. Current patient weight should always be used, except in patients with anasarca. In these cases, the patient's last known dry weight or the ideal weight should be used. For elderly patients whose weight is not known and who cannot be weighed because of the patient's clinical condition, a body mass index of 23 should be assumed.

CONCLUSION

The proposed nutrition table allows for management of optimal energy and protein intake for patients in different clinical situations, while respecting the different phases of the posttraumatic metabolic response, thus leading to favorable clinical outcomes.

Protein sparing therapies in acute illness and obesity: a review of George Blackburn's contributions to nutrition science

Protein sparing therapies were developed to mitigate the harms associated with protein-calorie malnutrition and nitrogen losses induced by either acute illness or hypocaloric diets in patients with obesity. We review the development of protein sparing therapies in illness and obesity with a focus on the pioneering contributions of George Blackburn, MD, PhD. He recognized that protein-calorie malnutrition is a common and serious clinical condition and developed new approaches to its treatment in hospitalized patients. His work with stable isotopes and with animal models provided answers about the physiological nutritional requirements and metabolic changes across a spectrum of conditions with varying degrees of stress and catabolism. This led to improvements in enteral and parenteral nutrition for patients with acute illness. Blackburn also demonstrated that lean body mass can be preserved during weight loss with carefully designed very low calorie treatments which became known as the protein sparing modified fast (PSMF). We review the role of the PSMF as part of the comprehensive management of obesity.

Optimal Energy Delivery, Rather than the Implementation of a Feeding Protocol, May Benefit Clinical Outcomes in Critically Ill Patients

Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01-2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.

Nutrition support in hospitalised adults at nutritional risk

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.

Nutrition and metabolism in burn patients

Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas.

Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Adjusted Body Weight, Con: Why Adjust Body Weight in Energy-Expenditure Calculations?

Evaluation of energy requirements of normal individuals and hospitalized patients is most often accomplished using an energy equation. Energy equations attempt to measure resting metabolic rate (RMR), the largest factor in total daily energy expenditure. Components of most energy equations include height, weight, age, and gender. These factors are related to energy expenditure; however, each factor has individual characteristics that affect energy expenditure. Body weight is a major factor in RMR and total daily energy expenditure. For obese individuals, estimation of energy expenditure may be a challenge due to the increased body weight. Therefore, some equations attempt to minimize the effect of body weight on energy expenditure assessment by adjusting the obese individual's body weight. Data do not support adjustment of body weight in normal individuals. In hospitalized patients, there are several equations that are used to estimate energy expenditure of obese patients, which include adjusting the body weight and modifying the overall energy requirements. Measurement of RMR can obviate the need for estimating energy expenditure. It is important to evaluate any energy-expenditure equation that is used to estimate energy needs in normal people and hospitalized patients before applying it to patient care.

Monitoring Energy Metabolism with Indirect Calorimetry: Instruments, Interpretation, and Clinical Application

Indirect calorimetry is the best measure to guide calorie administration during nutrition support. This article presents an update of the types of currently available indirect calorimeters and reviews the recent advances that guide the clinical application of indirect calorimetry. The emphasis of this report is placed on issues that the practicing clinician can use to evaluate, interpret, and apply measurements of energy expenditure.

Central Venous Access in the Home Parenteral Nutrition Population–You PICC

BACKGROUND

Central venous access is imperative for the delivery of home parenteral nutrition (HPN). Peripherally inserted central catheters (PICC) are being used more frequently for the delivery of HPN. There is an abundance of short-term information on the use of PICC in the hospitalized patient. However, there are no data comparing the use of PICC to other central venous access devices (OCVAD; Hickman, port) for the delivery of HPN. Catheter-related infections (CRI) are the most common cause of hospital readmission for the HPN patients.

METHODS

A retrospective analysis was performed from the Digestive Disease Center HPN database at the Medical University of South Carolina and the open architecture clinical information system (OACIS) hospital and clinic reporting system. All CRI were analyzed and compared between patients with PICC and OCVAD. The PICC group and the OCVAD group were further broken down into diabetic patients and nondiabetic patients, and the incidence of CRI was compared within those groups.

RESULTS

HPN patients with PICC had a statistically significant increase (p < .01) of CRI as compared with OCVAD within our HPN patients. There was no statistically significant increase in CRI between diabetic and nondiabetic patients.

CONCLUSIONS

The use of PICC for HPN may be associated with an increase in CRI. A prospective, randomized trial in the HPN population between PICC and OCVAD must be performed.

Nutrition and metabolism in burn patients

Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Hypocaloric Feeding of the Critically Ill

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.

The Bariatric Patient in the Intensive Care Unit: Pitfalls and Management

The increasing number of bariatric/metabolic operations as important alternatives for the treatment of obesity and type 2 diabetes brought several concerns about the intensive care of patients undergoing those procedures. Intensive Care Unit admission criteria are needed in order to better allocate resources and avoid unnecessary interventions. Furthermore, well-established protocols, helpful in many clinical situations, are not directly applicable to obese patients. Indeed, difficult airway management, mechanical ventilation, fluid therapy protocols, prophylaxis, and treatment of venous thromboembolic events have unique aspects that should be taken into consideration. Finally, new data related to planning nutrition therapy of the critically obese have been highlighted and deserve consideration. In this review, we provide an outline of recent studies related to those important aspects of the care of the bariatric/metabolic patients in critical conditions.

Parenteral Nutrition Basics for the Clinician Caring for the Adult Patient

Parenteral nutrition (PN) is a life-sustaining therapy providing nutrients to individuals with impaired intestinal tract function and enteral access challenges. It is one of the most complex prescriptions written routinely in the hospital and home care settings. This article is to aid the nutrition support clinician in the safe provision of PN, including selecting appropriate patients for PN, vascular access, development of a PN admixture, appropriate therapy monitoring, recognition of preparation options, and awareness of preparation and stability concerns.

Importance of Perioperative Blood Glucose Management in Cardiac Surgical Patients

Tight blood glucose control has become a therapeutic goal for anesthetic management of patients undergoing cardiovascular surgery. We discuss the evidence for a link between blood glucose levels and rates of morbidity and mortality in cardiac surgical patients in the intensive care unit. Hyperglycemia per se has been associated with higher rates of deep wound infection, neurologic, renal, and cardiac complications following surgery, as well as longer intensive care unit stay. We review the specifics of glucose management in patients undergoing cardiac surgery and hypothermic cardiopulmonary bypass, including the role that insulin may play in regulating blood glucose levels intraoperatively and the relationship between insulin and outcome.

Parenteral Nutrition and Infection Risk in the Intensive Care Unit: A Practical Guide for the Bedside Clinician

The safety of parenteral nutrition (PN) administration in critically ill patients has been the subject of much controversy. Historically, PN administration has been associated with an increased risk of bacterial and fungal infections, leading to significant morbidity and mortality. Much of the data showing increased infectious complications compared with either no nutrition or enteral nutrition was derived from early studies conducted in the 1980s-2000s. Poor glucose control and hyperalimentation are confounding factors in many early studies, making it difficult to determine the true PN infection risks. While PN studies conducted during the past 10 years have failed to show the same infection rates, these risks continue to be cited as dogma. Potential reasons for such discordant results include improved glycemic control, avoidance of overfeeding, and improved sterility and central venous catheter care. Understanding the true infectious risk of PN administration in the intensive care unit is necessary to optimize patient care, as inappropriately withholding such nutrition is potentially deleterious. This review is meant to serve as a practical guide to the bedside clinician who is evaluating the risks and benefits of initiating PN in a critically ill patient. Each component of PN will be evaluated based on risk of infection, and the potential ways to mitigate risks will be discussed.

Challenges in the Management of Geriatric Obesity in High Risk Populations

The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this “fat and frail” population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient’s nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.

Protein Requirements in the Critically Ill: A Randomized Controlled Trial Using Parenteral Nutrition

BACKGROUND

Current recommendations for higher protein/amino acid provision in the critically ill are based on weak evidence. This double-blinded randomized controlled trial aimed to compare standard amino acid intake with the higher level recommended as the minimum for critically ill patients.

METHODS

In total, 119 patients requiring parenteral nutrition (PN) in an intensive care unit (ICU) were randomized to receive blinded PN solutions containing amino acids at either 0.8 g/kg or 1.2 g/kg. Primary outcome was handgrip strength at ICU discharge. Secondary outcomes measured at study day 7 included handgrip strength, fatigue score (using the Chalder scale), and ultrasound measurements of muscle thickness at defined body sites. Analysis of covariance was used to control for age, sex, nutrition status (Subjective Global Assessment), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and baseline measurement.

RESULTS

Actual amino acid delivery to the 2 groups was 0.9 and 1.1 g/kg respectively, averaged over the first 7 days. Grip strength at ICU discharge was not significantly different between groups (P =054) despite being improved at study day 7 in the group receiving the higher level of amino acids (mean [SD], 22.1 [10.1] vs 18.5 [11.8] kg, P =025). These patients also had less fatigue (Chalder score, mean [SD], 5.4 [2.2] vs 6.2 [2.2], P = .045) and greater forearm muscle thickness on ultrasound (mean [SD], 3.2 [0.4] vs 2.8 [0.4] cm, P < .0001). Nitrogen balance was significantly better at study day 3 but not at day 7. There was no difference between groups in mortality or length-of-stay measures.

CONCLUSION

The higher level of amino acids was associated with small improvements in a number of different measures, supporting guideline recommendations for ICU patients. This trial was registered at Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) as ACTRN12609000366257.

Meta-analysis is not enough: The critical role of pathophysiology in determining optimal care in clinical nutrition

Evidence based medicine has preferably been based on prospective randomized controlled trials (PRCT's) and subsequent meta-analyses in many fields including nutrition and metabolism. These meta-analyses often yield convincing, contradictory or no proof of effectiveness. Consequently recommendations and guidelines of varying validity and quality have been published, often failing to convince the medical, insurance and government worlds to support nutritional care. Causes for lack of adequate proof of effectiveness are manifold. Many studies and meta-analyses lacked pathophysiological depth in design and interpretation. Study populations were not homogenous and endpoints not always clearly defined. Patients were included not at nutritional risk, unlikely to benefit from nutritional intervention. Others received nutrients in excess of requirements or tolerance due to organ failure. To include all available studies in a meta-analysis, study quality and homogeneity were only assessed on the basis of formal study design and outcome rather than on patient characteristics. Consequently, some studies showed benefit but included patients suffering harm, other studies were negative but contained patients that benefited. Recommendations did not always emphasize these shortcomings, confusing the medical and nutritional community and creating the impression that nutritional support is not beneficial. Strong reliance on meta-analyses and guidelines shifts the focus of education from studying clinical and nutritional physiology to memorizing guidelines. To prevent or improve malnutrition more physiological knowledge should be acquired to personalize nutritional practices and to more correctly value and evaluate the evidence. This also applies to the design and interpretation of PRCT's and meta-analyses.

Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults

BACKGROUND

The appropriate caloric goal for critically ill adults is unclear. We evaluated the effect of restriction of nonprotein calories (permissive underfeeding), as compared with standard enteral feeding, on 90-day mortality among critically ill adults, with maintenance of the full recommended amount of protein in both groups.

METHODS

At seven centers, we randomly assigned 894 critically ill adults with a medical, surgical, or trauma admission category to permissive underfeeding (40 to 60% of calculated caloric requirements) or standard enteral feeding (70 to 100%) for up to 14 days while maintaining a similar protein intake in the two groups. The primary outcome was 90-day mortality.

RESULTS

Baseline characteristics were similar in the two groups; 96.8% of the patients were receiving mechanical ventilation. During the intervention period, the permissive-underfeeding group received fewer mean (±SD) calories than did the standard-feeding group (835±297 kcal per day vs. 1299±467 kcal per day, P<0.001; 46±14% vs. 71±22% of caloric requirements, P<0.001). Protein intake was similar in the two groups (57±24 g per day and 59±25 g per day, respectively; P=0.29). The 90-day mortality was similar: 121 of 445 patients (27.2%) in the permissive-underfeeding group and 127 of 440 patients (28.9%) in the standard-feeding group died (relative risk with permissive underfeeding, 0.94; 95% confidence interval [CI], 0.76 to 1.16; P=0.58). No serious adverse events were reported; there were no significant between-group differences with respect to feeding intolerance, diarrhea, infections acquired in the intensive care unit (ICU), or ICU or hospital length of stay.

CONCLUSIONS

Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount of nonprotein calories. (Funded by the King Abdullah International Medical Research Center; PermiT Current Controlled Trials number, ISRCTN68144998.).

Enteral nutrition formula selection: current evidence and implications for practice

Many new enteral nutrition (EN) formulas have been created over the past several decades with a variety of intended uses. Although each is intended to promote improved outcomes, research is often unclear and, in many cases, conflicting. It is important to note that EN products are considered medical foods by the U.S. Food and Drug Administration and therefore do not have to complete premarket review or approval and are not regulated to the same extent as pharmaceuticals. While standard EN formulas are designed to meet the basic macro- and micronutrient requirements of individuals who cannot meet nutrition needs orally, specialty EN products have been developed to exhibit pharmacologic properties, such as immune-enhancing formulas containing arginine, glutamine, nucleotides, and ω-3 fatty acids. With the vast number of products available, rising costs of healthcare, and the drive toward evidence-based practice, it is imperative that clinicians carefully consider research regarding use of specialty formulas, paying close attention to the quality, patient population, clinical end points, and cost to patient and/or facility.

Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: a randomized controlled trial

BACKGROUND

Proper caloric intake goals in critically ill surgical patients are unclear. It is possible that overnutrition can lead to hyperglycemia and an increased risk of infection.

OBJECTIVE

This study was conducted to determine whether surgical infection outcomes in the intensive care unit (ICU) could be improved with the use of hypocaloric nutritional support.

DESIGN

Eighty-three critically ill patients were randomly allocated to receive either the standard calculated daily caloric requirement of 25-30 kcal · kg(-1) · d(-1) (eucaloric) or 50% of that value (hypocaloric) via enteral tube feeds or parenteral nutrition, with an equal protein allocation in each group (1.5 g · kg(-1) · d(-1)).

RESULTS

There were 82 infections in the hypocaloric group and 66 in the eucaloric group, with no significant difference in the mean (± SE) number of infections per patient (2.0 ± 0.6 and 1.6 ± 0.2, respectively; P = 0.50), percentage of patients acquiring infection [70.7% (29 of 41) and 76.2% (32 of 42), respectively; P = 0.57], mean ICU length of stay (16.7 ± 2.7 and 13.5 ± 1.1 d, respectively; P = 0.28), mean hospital length of stay (35.2 ± 4.9 and 31.0 ± 2.5 d, respectively; P = 0.45), mean 0600 glucose concentration (132 ± 2.9 and 135 ± 3.1 mg/dL, respectively; P = 0.63), or number of mortalities [3 (7.3%) and 4 (9.5%), respectively; P = 0.72]. Further analyses revealed no differences when analyzed by sex, admission diagnosis, site of infection, or causative organism.

CONCLUSIONS

Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.

Standardized versus custom parenteral nutrition: impact on clinical and cost-related outcomes

PURPOSE

Results of a study comparing clinical and cost outcomes with the use of standardized versus custom-prepared parenteral nutrition (PN) in an acute care setting are reported.

METHODS

In a retrospective pre-post analysis, nutritional target attainment, electrolyte abnormalities, and other outcomes were compared in patients 15 years of age or older who received custom PN (n = 49) or a standardized PN product (n = 57) for at least 72 hours at a large medical center over a 13-month period; overall, 45% of the cases were intensive care unit (ICU) admissions. A time-and-motion assessment was conducted to determine PN preparation times.

RESULTS

There were no significant between-group differences in the percentage of patients who achieved estimated caloric requirements or in mean ICU or hospital length of stay. However, patients who received standardized PN were significantly less likely than those who received custom PN to achieve the highest protein intake goal (63% versus 92%, p = 0.003) and more likely to develop hyponatremia (37% versus 14%, p = 0.01). Pharmacy preparation times averaged 20 minutes for standardized PN and 80 minutes for custom PN; unit costs were $61.06 and $57.84, respectively.

CONCLUSION

A standardized PN formulation was as effective as custom PN in achieving estimated caloric requirements, but it was relatively less effective in achieving 90% of estimated protein requirements and was associated with a higher frequency of hyponatremia. The standardized PN product may be a cost-effective formulation for institutions preparing an average of five or fewer PN orders per day.