Early enteral nutrition in mechanically ventilated patients in the prone position

Nutrition delivery across hospitalisation in critically ill patients with COVID-19: An observational study of the Australian experience

BACKGROUND

Data on nutrition delivery over the whole hospital admission in critically ill patients with COVID-19 are scarce, particularly in the Australian setting.

OBJECTIVES

The objective of this study was to describe nutrition delivery in critically ill patients admitted to Australian intensive care units (ICUs) with coronavirus disease 2019 (COVID-19), with a focus on post-ICU nutrition practices.

METHODS

A multicentre observational study conducted at nine sites included adult patients with a positive COVID-19 diagnosis admitted to the ICU for >24 h and discharged to an acute ward over a 12-month recruitment period from 1 March 2020. Data were extracted on baseline characteristics and clinical outcomes. Nutrition practice data from the ICU and weekly in the post-ICU ward (up to week four) included route of feeding, presence of nutrition-impacting symptoms, and nutrition support received.

RESULTS

A total of 103 patients were included (71% male, age: 58 ± 14 years, body mass index: 30±7 kg/m2), of whom 41.7% (n = 43) received mechanical ventilation within 14 days of ICU admission. While oral nutrition was received by more patients at any time point in the ICU (n = 93, 91.2% of patients) than enteral nutrition (EN) (n = 43, 42.2%) or parenteral nutrition (PN) (n = 2, 2.0%), EN was delivered for a greater duration of time (69.6% feeding days) than oral and PN (29.7% and 0.7%, respectively). More patients received oral intake than the other modes in the post-ICU ward (n = 95, 95.0%), and 40.0% (n = 38/95) of patients were receiving oral nutrition supplements. In the week after ICU discharge, 51.0% of patients (n = 51) had at least one nutrition-impacting symptom, most commonly a reduced appetite (n = 25; 24.5%) or dysphagia (n = 16; 15.7%).

CONCLUSION

Critically ill patients during the COVID-19 pandemic in Australia were more likely to receive oral nutrition than artificial nutrition support at any time point both in the ICU and in the post-ICU ward, whereas EN was provided for a greater duration when it was prescribed. Nutrition-impacting symptoms were common.

Association between protocol change to a higher-protein formula with lower energy targets and nutrient delivery in critically ill patients with COVID-19: A retrospective cohort study

BACKGROUND

Guidelines recommend prioritizing protein provision while avoiding excessive energy delivery to critically ill patients with coronavirus disease 2019 (COVID-19), but there are no prospective studies evaluating such a targeted approach in this group. We aimed to evaluate the effect of a "higher-protein formula protocol" on protein, energy, and volume delivery when compared with standard nutrition protocol.

METHODS

This was a retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation for >72 h and enteral nutrition. Before October 2021, the standard nutrition protocol for patients was 0.7 ml/kg/h ideal body weight (IBW) of a 63 g/L protein and 1250 kcal/L formula. From October 2021, we implemented a higher-protein formula protocol for patients with COVID-19. The initial prescription was 0.5 ml/kg/h IBW of a 100 g/L protein and 1260 kcal/L formula with greater emphasis on energy targets being directed by indirect calorimetry when possible. Measured outcomes included protein, energy, and volume delivered.

RESULTS

There were 114 participants (standard protocol, 48; higher-protein protocol, 66) with 1324 days of nutrition support. The median (95% CI) differences in protein, energy, and volume delivery between targeted and standard protocol periods were 0.08 g/kg/day (-0.02 to 0.18 g/kg/day), -1.71 kcal/kg/day (-3.64 to 0.21 kcal/kg/day) and -1.5 ml/kg/day (-2.9 to -0.1 ml/kg/day). Thirty-three patients (standard protocol, 7; higher-protein protocol, 26) had 44 indirect calorimetry assessments. There was no difference in measured energy expenditure over time (increased by 0.49 kcal/kg/day [-0.89 to 1.88 kcal/kg/day]).

CONCLUSION

Implementation of a higher-protein formula protocol to patients with COVID-19 modestly reduced volume administration without impacting protein and energy delivery.

Enteral nutrition practice in the prone position in patients with coronavirus disease 2019: An international one-day point prevalence analysis

BACKGROUND & AIMS

Enteral nutrition (EN) in the prone position for severe respiratory failure is considered possible with care. However, the extent to which it is feasible, especially its association with the length of intensive care unit (ICU) stay, is unclear. Therefore, we investigated the relationship between the duration of prone position therapy and adequacy of EN delivery and explored factors associated with this relationship in an observational study of critically ill patients with coronavirus disease 2019 (COVID-19) who were actively treated in the prone position.

METHODS

This study was a secondary analysis of a worldwide one-day prevalence study in the COVID-19 era. We investigated the care and nutritional therapy provided to critically ill patients with COVID-19 admitted to ICU, along with ICU-related information. We targeted patients who received only tube feeding and analyzed the relationship between the duration of prone position, length of ICU stays, and nutrition delivery via EN. In addition, a multivariate analysis was performed to examine factors affecting the achievement of EN delivery of 20 kcal/kg/day or more in patients who were placed in the prone position for at least 6 h.

RESULTS

A total of 399 patients who received only EN, excluding parenteral nutrition and oral intake, were included, of whom 58 % received EN energy delivery of ≥20 kcal/kg/day; this rate increased with the length of ICU stay, regardless of the duration of prone position. In a multivariate analysis of 121 patients who were in the prone position for at least 6 h, the presence of dedicated dietitians in the ICU (OR = 6.91, 95 % CI = 1.98 to 24.1, p < 0.01) was associated with a higher energy delivery. Conversely, the use of muscle relaxants (OR = 0.32, 95 % CI = 0.11 to 0.98, p = 0.04) and presence of nutrition protocols (OR = 0.24, 95 % CI = 0.07 to 0.77, p = 0.02) was associated with a lower energy delivery.

CONCLUSIONS

Patients with COVID-19 received adequate nutrition by EN even during prone position. Target EN delivery would be achieved with the introduction of prone position.

Enteral feeding tolerance during pharmacologic neuromuscular blockade

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Strategies to preventing pressure injuries among intensive care unit patients mechanically ventilated in prone position: a systematic review and a Delphi study

Background

Although the incidence of pressure injury in the prone position is high for the mechanically ventilated patients in the intensive care unit, evidence-based strategies are still lacking.

Propose

To conduct a systematic review of current evidence, and to propose a series of strategies to prevent pressure injuries among mechanically ventilated patients with prone position in the intensive care unit.

Methods

The study was guided by the Medical Research Council framework. After a systematic review of current evidence of original articles, guidelines, expert consensus and theories, a strategy draft was developed. Then we invited 20 experts to modify and refine these strategies through two rounds of Delphi consensus method.

Results

After two rounds of Delphi process, the importance of coefficient of variation (Cv) and Kendall's coefficient of concordance in the strategies repository were 0.067 and 0.311, respectively. And the operability of Cv and Kendall's coefficient of concordance in the strategy draft was 0.055 and 0.294, respectively. Ultimately, we established 31 strategies for including 7 themes (assess risk factors, assess skin and tissue, body position management, skin care, nutrition, preventing medical device-related pressure injuries, education and supervision). In addition, we also developed a strategy framework to clarify our strategies.

Conclusion

According to the Medical Research Council framework, we developed 7 themes and 31 strategies to prevention prone-position pressure injuries among the intensive care unit mechanically ventilated patients. This study was considered to improve the clinical management of pressure injuries among prone position patients in the intensive care unit settings.

Enteral Nutrition Safety and Outcomes of Patients with COVID-19 on Continuous Infusion of Neuromuscular Blockers: A Retrospective Study

Background

Intravenous infusions of neuromuscular blocking agents (NMBAs) and prone positioning are recommended for acute respiratory distress syndrome (ARDS) due to COVID-19. The safety of enteral nutrition (EN) during these treatments is unclear. This study assessed EN tolerance and safety during NMBA infusion in proned and nonproned patients with ARDS due to COVID-19.

Methods

This retrospective study evaluated patients who were admitted to a tertiary-care ICU between March and December 2020, had ARDS due to COVID-19, and received NMBA infusion. We assessed their EN data, gastrointestinal events, and clinical outcomes. The primary outcome was gastrointestinal intolerance, defined as a gastric residual volume (GRV) ≥500 ml or 200-500 ml with vomiting. We compared proned and nonproned patients.

Results

We studied 181 patients (mean age 61.2 ± 13.7 years, males 71.1%, and median body mass index 31.4 kg/m2). Most (63.5%) patients were proned, and 94.3% received EN in the first 48 hours of NMBA infusion at a median dose <10 kcal/kg/day. GRV was mostly below 100 ml. Gastrointestinal intolerance occurred in 6.1% of patients during NMBA infusion and 10.5% after NMBA discontinuation (similar rates in proned and nonproned patients). Patients who had gastrointestinal intolerance during NMBA infusion had a higher hospital mortality (90.9% versus 60.0%; p=0.05) and longer mechanical ventilation duration and ICU and hospital stays compared with those who did not.

Conclusion

In COVID-19 patients on NMBA infusion for ARDS, EN was provided early at low doses for most patients, and gastrointestinal intolerance was uncommon in proned and nonproned patients, occurred at a higher rate after discontinuing NMBAs and was associated with worse outcomes. Our study suggests that EN was tolerated and safe in this patient population.

Nutrition intake in critically ill patients with coronavirus disease (COVID-19): A nationwide, multicentre, observational study in Argentina

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with coronavirus disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March and October 2020.

INCLUSION CRITERIA

Adult ICU patients>18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48h. Statistical analysis was carried out using IBM-SPSS© 24 programme.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97g/kg/day (CI 0.95-0.99), P<0.001), and lower caloric intake than those who survived (12.94kcal/kg/day (CI 12.48-13.39) vs 16.47kcal/kg/day (CI 16.09-16.8), P<0.001). A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II>18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.

Feeding intolerance during prolonged prone position in overweight and obese patients with severe COVID-19

OBJECTIVE

the aim of this study was to compare the incidence rate of feeding intolerance (FI) during supine (SP) or prone positioning (PP) in critically ill COVID-19 patients.

METHODS

this was a retrospective cohort study of critically ill patients with overweight or obesity who received enteral nutrition (EN) in prone or supine positioning continuously during the first five days of mechanical ventilation. Nutritional risk, anthropometric measurements and body composition were assessed at the first 24 hours upon Intensive Care Unit (ICU) admission. Biochemical and clinical variables (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation II [APACHE II], Acute Kidney Injury [AKI] or comorbidities diagnosis) were collected. Pharmacotherapy (prokinetics, sedatives or neuromuscular blocking agents) and FI incidence (gastric residual volume [GRV] ≥ 200 ml or ≥ 500 ml, vomiting or diarrhea) were daily recorded. Constipation was defined as the absence of evacuation for five consecutive days.

RESULTS

eighty-two patients were included. Higher rate of prophylactic prokinetic prescription was observed in PP (42.8 vs 12.5 %, p = 0.002). GRV ≥ 200 in supine position was not different when compared to PP (p = 0.47). Vomiting episodes in supine compared to PP showed no difference between groups (15 % vs 24 %, p = 0.31). No differences in diarrhea events were detected (10 % vs 4.7 %, p = 0.36). Constipation was common in both groups (95 % vs 82 %, p = 0.06).

CONCLUSION

FI during prone position was not different in comparison to supine position. Routinely use of prokinetics in continuous prone position may help to prevent FI incidence. Algorithm development is necessary for FI prevention and treatment so to avoid EN interruptions and adverse clinical outcomes.

Gastric Cross-Sectional Area to Predict Gastric Intolerance in Critically Ill Patients: The Sono-ICU Prospective Observational Bicenter Study

To evaluate the correlation between gastric cross-sectional area (GCSA) and the occurrence of gastric intolerance in critically ill patients within 24 hours of the measurement.

DESIGN

Two-center prospective observational study.

SETTING

Two academic ICUs in France between June 2020 and August 2021.

PATIENTS

All surgical intubated ICU patients greater than or equal to 18 years old receiving enteral feeding for greater than 12 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-four patients were included, 11 (25%) of whom presented digestive intolerance. Primary outcome was assessment of the association between GCSA and the occurrence of gastric intolerance within 24 hours of the measurement. GCSA value was significantly higher in patients with upper digestive intolerance compared to those without (553 mm² [interquartile range (IQR), 500-649 mm²] vs 970 mm² [IQR, 777-1,047]; p < 0.001, respectively). The optimal threshold for predicting upper digestive intolerance was 720 mm² (area under the receiver operating characteristic curve 0.86; positive predictive value 62.5%; negative predictive value 96.4%; sensibility 0.91; and specificity 0.81). Multivariate analysis (weighted by propensity score), including known risk factors, showed that GCSA above the 720 mm² threshold was independently associated with the occurrence of upper digestive intolerance (odds ratio, 1.85; 1.37-2.49; p < 0.0002). Measurement quality was "good" (i.e., liver, aorta, superior mesenteric vein, and pancreas were all visualized) in 81% of cases.

CONCLUSIONS

Measurement of GCSA by ultrasound would allow prediction of gastric intolerance in critically ill patients. This should be confirmed by a prospective score validation and interventional trials.

[Nutrition Intake in Critically Ill Patients with Coronavirus Disease (Covid-19): A Nationwide, Multicentre, Observational Study in Argentina]

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with Coronavirus Disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March-October 2020.

INCLUSION CRITERIA

Adult ICU patients >18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48hs. Statistical analysis was carried out using IBM-SPSS© 24 program.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73 g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97 g/kg/day (CI 0.95-0.99), P <0.001), and lower caloric intake than those who survived (12.94 kcal/kg/day (CI 12.48-13.39) vs 16.47 kcal/kg/day (CI 16.09-16.8), P <0.001).A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II >18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.[[[es]]]RESUMENIntroducción: En 2020, la pandemia provocada por el SARS-COV-2, demandó una enorme cantidad de recursos sanitarios para garantizar el tratamiento y apoyo adecuado a estos pacientes. Este estudio tiene como objetivo evaluar la ingesta de calorías/proteínas y evaluar sus asociaciones con resultados clínicos relevantes en pacientes críticamente enfermos con enfermedad por coronavirus (COVID-19).Métodos: Se realizó un estudio observacional prospectivo multicéntrico a nivel nacional que incluyó 12 unidades de cuidados intensivos (UCI) argentinas entre marzo y octubre de 2020. Criterios de inclusión: pacientes adultos de la UCI > 18 años ingresados en la UCI con diagnóstico de COVID-19 y ventilación mecánica durante al menos 48 horas. El análisis estadístico se realizó mediante el programa IBM-SPSS© 24.

RESULTADOS

En el presente estudio se incluyeron 185 pacientes. Entre los que fallecieron se observó un aporte proteico más bajo (0,73 g/kg/día (intervalo de confianza (IC) del 95 % 0,70-0,75 frente a 0,97 g/kg/día (IC 0,95-0,99), P < 0,001), y menor aporte calórico que los que sobrevivieron (12,94 kcal/kg/día (IC 12,48-13,39) vs 16,47 kcal/kg/día (IC 16,09-16,8), P < 0,001).Se construyó un modelo de regresión logística para analizar qué factores estaban asociados con la probabilidad de lograrlos objetivos calóricos/proteicos. Se observo una mayor probabilidad de lograr dichos objetivos cuando el inicio del soporte nutricional era precoz, el puntaje NUTRIC modificado era superior a 5 puntos y el paciente tenía diagnóstico de desnutrición mediante la Evaluación Global Subjetiva(B o C). Por otra parte, en los pacientes que necesitaron ventilación mecánica en decúbito prono se observó menor aporte calórico y proteico, situación similar en aquellos con APACHE II > 18.

CONCLUSIONES

Los pacientes críticos con insuficiencia respiratoria asociada a la enfermedad por COVID-19 que requerían ventilación mecánica y que fallecieron en la UCI tuvieron una ingesta calórica y proteica menor que los que sobrevivieron. El inicio temprano del soporte nutricional y la desnutrición aumentaron la posibilidad de alcanzar los objetivos calóricos y proteicos, mientras que la gravedad de la enfermedad y la ventilación mecánica en decúbito prono disminuyeron la posibilidad de alcanzar los objetivos calóricos y proteicos.

Nutritional management of individuals with obesity and COVID-19: ESPEN expert statements and practical guidance

The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerged along with undernutrition-malnutrition as a strong predictor of disease risk and severity. Obesity-related excessive body fat may lead to respiratory, metabolic and immune derangements potentially favoring the onset of COVID-19 complications. In addition, patients with obesity may be at risk for loss of skeletal muscle mass, reflecting a state of hidden malnutrition with a strong negative health impact in all clinical settings. Also importantly, obesity is commonly associated with micronutrient deficiencies that directly influence immune function and infection risk. Finally, the pandemic-related lockdown, deleterious lifestyle changes and other numerous psychosocial consequences may worsen eating behaviors, sedentarity, body weight regulation, ultimately leading to further increments of obesity-associated metabolic complications with loss of skeletal muscle mass and higher non-communicable disease risk. Therefore, prevention, diagnosis and treatment of malnutrition and micronutrient deficiencies should be routinely included in the management of COVID-19 patients in the presence of obesity; lockdown-induced health risks should also be specifically monitored and prevented in this population. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing clinical practice guidance for nutritional management of COVID-19 patients with obesity in various clinical settings.

Administration of enteral nutrition and gastrointestinal complications in Covid-19 critical patients in prone position

Background

The prone position (PP) used in the treatment of critically ill patients infected with SARS-CoV-2, may be a barrier to enteral nutrition (EN). This study aimed to analyze the effectiveness and complications of EN in the PP, as well as clinical outcomes.

Methods

Prospective cohort study with patients in EN and coronavirus disease 2019 (COVID-19), on mechanical ventilation (MV), which whom needed or not PP. Gastrointestinal intolerances (GII) related to PP were evaluated, and correlated with possible confounding factors. EN, days on MV, Intensive Care Unit (ICU) length of stay, hospital length of stay, ventilator-associated pneumonia (VAP) and mortality were analyzed. The data were evaluated daily and compared prone group (PG=57) and supine group (SG=69).

Results

The PP was associated with GII (P=0.000) and presented in 32 patients (26,44%) with no difference among groups. Association between epinephrine (P=0.003), vasopressin (P=0.018), and GII was observed. There was no difference between the total volume of enteral nutrition (TVEN) infused in the groups. However, the mean EN infused for the days when the patient was on PP was (70.0% ± 31.5) and for the days in supine position was (74.8% ± 27.3), P= 0.006. The PG had a longer time on MV (P=0.005) and ICU (P=0.003) and PP was associated with VAP (P=<0.001). The infused TVEN showed no association with VAP (P=0.09).

Conclusion

PP was a determining factor in GII and proved to be a risk factor for VAP, but the EN protocol seems to have ensured an adequate EN supply in PP and be a safe alternative.

The Role of Obesity, Body Composition, and Nutrition in COVID-19 Pandemia: A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic has spread worldwide, infecting nearly 500 million people, with more than 6 million deaths recorded globally. Obesity leads people to be more vulnerable, developing worse outcomes that can require hospitalization in intensive care units (ICU). This review focused on the available findings that investigated the link between COVID-19, body composition, and nutritional status. Most studies showed that not only body fat quantity but also its distribution seems to play a crucial role in COVID-19 severity. Compared to the body mass index (BMI), visceral adipose tissue and intrathoracic fat are better predictors of COVID-19 severity and indicate the need for hospitalization in ICU and invasive mechanical ventilation. High volumes of epicardial adipose tissue and its thickness can cause an infection located in the myocardial tissue, thereby enhancing severe COVID-related myocardial damage with impairments in coronary flow reserve and thromboembolism. Other important components such as sarcopenia and intermuscular fat augment the vulnerability in contracting COVID-19 and increase mortality, inflammation, and muscle damage. Malnutrition is prevalent in this population, but a lack of knowledge remains regarding the beneficial effects aimed at optimizing nutritional status to limit catabolism and preserve muscle mass. Finally, with the increase in patients recovering from COVID-19, evaluation and treatment in those with Long COVID syndrome may become highly relevant.

Challenges to Provision of Adequate Medical Nutrition Therapy in a Critically Ill COVID-19 Patient Fed in the Prone Position

Adults with acute respiratory distress syndrome (ARDS) may experience enteral nutrition (EN) intolerance. They often require mechanical ventilation and other specialized management including prone positioning. There is a controversy as to whether patients fed in prone position experience more EN intolerance than when they are in supine position. This narrative review synthesizes the literature published between 2001 and 2021 in adults with ARDS who are fed EN while in the prone position to determine safety and tolerance. A case of an adult patient with Down syndrome who developed ARDS due to COVID-19 and required EN while in prone position is presented.

Enteral Nutrition Overview

Enteral nutrition (EN) provides critical macro and micronutrients to individuals who cannot maintain sufficient oral intake to meet their nutritional needs. EN is most commonly required for neurological conditions that impair swallow function, such as stroke, amytrophic lateral sclerosis, and Parkinson’s disease. An inability to swallow due to mechanical ventilation and altered mental status are also common conditions that necessitate the use of EN. EN can be short or long term and delivered gastrically or post-pylorically. The expected duration and site of feeding determine the type of feeding tube used. Many commercial EN formulas are available. In addition to standard formulations, disease specific, peptide-based, and blenderized formulas are also available. Several other factors should be considered when providing EN, including timing and rate of initiation, advancement regimen, feeding modality, and risk of complications. Careful and comprehensive assessment of the patient will help to ensure that nutritionally complete and clinically appropriate EN is delivered safely.

Caloric Intake with High Ratio of Enteral Nutrition Associated with Lower Hospital Mortality for Patients with Acute Respiratory Distress Syndrome Using Prone Position Therapy

Positioning patients in the prone position leads to reduced hospital mortality rates for those with severe acute respiratory distress syndrome (ARDS). What constitutes the optimal feeding strategy for prone patients with ARDS is controversial. We conducted a retrospective study that enrolled 110 prone patients with ARDS in two medical intensive care units (ICUs) from September 2015 to November 2018. Inclusion criteria were as follows: age ≥20 years, diagnosis of respiratory failure requiring mechanical ventilation, diagnosis of ARDS within 72 h of ICU admission, placement in a prone position within the first 7 days of ICU admission, and ICU stay of more than 7 days. Exclusion criteria were as follows: nil per os orders because of gastrointestinal bleeding or hemodynamic instability, and ventilator dependency because of chronic respiratory failure. The consecutive daily enteral nutrition(EN)/EN + parenteral nutrition(PN) ratio could predict hospital mortality rates within the first 7 days of admission when using generalized estimating equations (p = 0.013). A higher average EN/EN + PN ratio within the first 7 days predicted (hazard ratio: 0.97, confidence interval: 0.96-0.99) lower hospital mortality rates. To reduce hospital mortality rates, caloric intake with a higher EN ratio may be considered for patients in prone positions with ARDS.

Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07-0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

A Quick Review on the Multisystem Effects of Prone Position in Acute Respiratory Distress Syndrome (ARDS) Including COVID-19

Objective:

The purpose of this review is to highlight the multisystem effects of prone position in ARDS patients with a focus on current findings regarding its use in COVID-19 patients.

Methods:

Two reviewers comprehensively searched PubMed database for literature regarding pathophysiology and efficacy of prone position in ARDS patients as well as specific data regarding this approach in COVID-19 patients.

Conclusion:

Prone positioning is well-documented to improve oxygenation and cardiac function in ARDS patients and might confer increased survival, with benefits that outweigh risks such as facial edema, endotracheal tube displacement, and intraabdominal organ dysfunction in obese patients. Severe COVID-19 pneumonia, while meeting ARDS criteria, differs from typical ARDS in several ways. Data would suggest that advantages of prone position would become limited after significant disease progression and fibrosis. The use of this technique in COVID-19 requires prolonged sessions that are unprecedented in the treatment of ARDS patients. New data regarding COVID-19 pathophysiology and patients continues to evolve daily. More frequently, patients are proned while maintaining spontaneous breathing—the results of this intervention are an area for future studies. There is more to learn about the appropriate use of prone position in COVID-19 patients. The multisystem risks and benefits require clinicians to adopt a patient centered decision-making algorithm when employing this technique in COVID-19 patients.

Level of evidence:

NA

Fluoroscopic placement of nasojejunal feeding tubes in COVID-19 patients in the prone position

Background

Coronavirus disease 2019 (COVID‐19) has caused an increase in patients requiring enteral feeding access while undergoing proning for severe acute respiratory distress syndrome (ARDS). We investigated the safety and feasibility of fluoroscopy‐guided nasojejunal (NJ) feeding tube placement in the prone position.

Methods

This is a retrospective cohort study of all patients who underwent fluoroscopic placement of NJ feeding tubes at a single institution between March 2020 and December 2020. Primary end points were success rate and number of attempts. Chi‐squared and Fischer exact tests were used to compare prone and supine groups.

Results

A total of 210 patients were included in the study: 53 patients received NJ feeding tubes while prone and 157 while supine. All but one patient in the prone group had ARDS secondary to COVID‐19, whereas 47 (30.3%) had COVID‐19 in the supine group. The rate of successful placement was 94.3% in the prone group and 100% in the supine group. Mean number of attempts was 1.1 (SD, ±0.4) in the prone and 1.0 (SD, ±0.1) in the supine group (P = .14). Prone patients had a longer median fluoroscopy time (69 s, interquartile range [IQR] = 92; vs 48 s, IQR = 43; P < .001) and received a higher radiation dose during the procedure (47 mGy, IQR = 50; vs 25 mGy, IQR = 33; P = .004). No procedural complications were reported.

Conclusion

Fluoroscopy‐guided NJ feeding tube placement in prone patients is feasible and safe. Patient positioning should not delay obtaining postpyloric feeding access.

[The XI SENPE Jesús Culebras Lecture. Enteral nutrition in critically ill patients. History of an evolution]

Introduction

Enteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

How Differences in the Disease Process of the COVID-19 Pandemic Pose Challenges to the Delivery of Critical Care Nutrition

PURPOSE OF REVIEW

The COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support.

RECENT FINDINGS

Prolonged hyperinflammation, unlike any previously described pattern of response to injury, causes metabolic perturbations and deterioration of nutritional status. High ventilatory demands, hypercoagulation with the risk of bowel ischemia, and threat of aspiration in patients with little or no pulmonary reserve, thwart initial efforts to provide early enteral nutrition (EN). The obesity paradox is invalidated, tolerance of EN is limited, intensivists are reluctant to add supplemental parenteral nutrition (PN), and efforts to give sufficient nutritional therapy remain a low priority. The nature of the disease and difficulties providing traditional critical care nutrition lead to dramatic deterioration of nutritional status. Institutions should not rely on insufficient gastric feeding alone but focus instead on redoubling efforts to provide postpyloric deep duodenal/jejunal EN or re-examine the role of supplemental PN in this population of patients with such severe critical illness.

Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers

This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.

Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19

Prone ventilation refers to the delivery of mechanical ventilation with the patient lying in the prone position. The improvement of oxygenation during prone ventilation is multifactorial, but occurs mainly by reducing lung compression and improving lung perfusion. CT imaging modeling data demonstrated that the asymmetry of lung shape leads to a greater induced pleural pressure gravity gradient when supine as compared to prone positioning. Although proning is indicated in patients with severe ARDS who are not responding to other ventilator modalities, this technique has moved away from a salvage therapy for refractory hypoxemia to an upfront lung-protective strategy intended to improve survival in severe ARDS, especially due to the current COVID-19 pandemic. In view of different roles, we surgeons had to take during the COVID-19 pandemic, it is of importance to learn how to implement this therapeutic measure, especially in a surgical critical care unit setting. As such, this article aims to review the physiological principles and effects of the prone ventilation, positioning, as well as its contraindications and complications.

Nutrition Support During Prone Positioning: An Old Technique Reawakened by COVID-19

Acute respiratory distress syndrome (ARDS) is a complex disease characterized by inflammation, resulting in diffuse alveolar damage, proliferation, and fibrosis, and carries a high mortality rate. Recently, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has overwhelmed healthcare systems worldwide, as many patients have required hospitalization for the management of respiratory failure similar in nature to ARDS. In addition to lung-protective ventilation strategies aimed to maintain an oxygen saturation >90%, a ratio of partial pressure of oxygen to fraction of inspired oxygen >200, a pH of 7.25-7.40, and a plateau pressure <35 cm H₂ O, prone positioning has emerged as an effective treatment strategy for severe ARDS by improving oxygenation and secretion clearance. Although early nutrition assessment and intervention are recommended for acutely and critically ill patients, rotational therapy may present challenges in providing this care. Here, we will describe the pathophysiology of ARDS and the rationale for use of prone positioning and review the considerations and challenges of providing nutrition therapy for patients in the prone position.

Nursing issues in enteral nutrition during prone position in critically ill patients: A systematic review of the literature

BACKGROUND

Early enteral nutrition (EN) and prone position may both improve the outcome of patients affected by moderate to severe Acute Respiratory Distress Syndrome. Recent guidelines suggest to administer early EN also during prone position. However, EN intolerance, such as high residual gastric volumes, regurgitation or vomiting, may occur during pronation.

AIM

This systematic review aims to assess the occurrence of high residual gastric volume, regurgitation or vomiting episodes, that can be encountered in patients receiving EN during prone position.

METHODS

We have conducted a systematic review. We queried three scientific databases (MEDLINE, EMBASE and CINAHL) from inception until November 19, 2019 without language restrictions, using keywords and related MeSH terms. All relevant articles enrolling adult patients receiving invasive mechanical ventilation and evaluating the use of early EN during prone position were included.

RESULTS

From 111 records obtained, we included six studies. All studies but one reported no differences with respect to gastric residual volumes between supine and prone positions. A 24-hours EN administration protocol seems to be better, as compared to an 18-hours feeding protocol. The need to stop EN and vomiting episodes were higher during prone position, although the rate of high gastric volume was similar between supine and prone positions. Ventilator associated pneumonia, lengths of stay and mortalities were similar between supine and prone positions. Only one study reported lower mortality in patients receiving EN throughout the entire day, as compared to an 18-hours administration protocol.

CONCLUSION

Protocols should be followed by healthcare providers in order to increase the enteral feeding volume, while avoiding EN intolerance (such as EN stops, high residual volume, regurgitation and vomiting).

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.

Gastrointestinal Manifestations of COVID-19: Impact on Nutrition Practices

Although Coronavirus disease 2019 (COVID‐19) is primarily a respiratory disease, growing evidence shows that it can affect the digestive system and present with gastrointestinal (GI) symptoms. Various nutrition societies have recently published their guidelines in context of the pandemic, and several points emphasize the impact of these GI manifestations on nutrition therapy. In patients with COVID‐19, the normal intestinal mucosa can be disrupted by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) virus, and this could result in GI symptoms and a compromise in nutrient absorption. Optimization of oral diet is still recommended. However, given the GI effects of COVID‐19, a fraction of infected patients have poor appetite and would not be able to meet their nutrition goals with oral diet alone. For this at‐risk group, which includes those who are critically ill, enteral nutrition is the preferred route to promote gut integrity and immune function. In carrying this out, nutrition support practices have been revised in such ways to mitigate viral transmission and adapt to the pandemic. All measures in the GI and nutrition care of patients are clustered to limit exposure of healthcare workers. Among patients admitted to intensive care units, a significant barrier is GI intolerance, and it appears to be exacerbated by significant GI involvement specific to the SARS‐CoV‐2 infection. Nevertheless, several countermeasures can be used to ease side effects. At the end of the spectrum in which intolerance persists, the threshold for switching to parenteral nutrition may need to be lowered.

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosole exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.

Donning a New Approach to the Practice of Gastroenterology: Perspectives From the COVID-19 Pandemic Epicenter

The COVID-19 pandemic seemingly is peaking now in New York City and has triggered significant changes to the standard management of gastrointestinal diseases. Priorities such as minimizing viral transmission, preserving personal protective equipment, and freeing hospital beds have driven unconventional approaches to managing gastroenterology (GI) patients. Conversion of endoscopy units to COVID units and redeployment of GI fellows and faculty has profoundly changed the profile of most GI services. Meanwhile, consult and procedural volumes have been reduced drastically. In this review, we share our collective experiences regarding how we have changed our practice of medicine in response to the COVID surge. Although we review our management of specific consults and conditions, the overarching theme focuses primarily on noninvasive measures and maximizing medical therapies. Endoscopic procedures have been reserved for those timely interventions that are most likely to be therapeutic. The role of multidisciplinary discussion, although always important, now has become critical. The support of our faculty and trainees remains essential. Local leadership can encourage well-being by frequent team check-ins and by fostering trainee development through remote learning. Advancing a clear vision and a transparent process for how to organize and triage care in the recovery phase will allow for a smooth transition to our new normal.

COVID-19 disease: invasive ventilation

This article focuses on the critical care nurse's role in the management of patients with COVID-19 who require invasive ventilation in order to improve outcomes and prevent complications. The nature of COVID-19 is such that many patients deteriorate rapidly and for members of this group requiring intubation and invasive ventilation, different approaches to airway management and ventilatory support are required. In order to reduce the risk of complications and an overview of invasive ventilation, including commonly used modes, potential complications, nursing care, weaning and extubation are all described. COVID-19 presents several challenges as the disease progresses, hypoxemia may worsen, and the patient can develop Acute Respiratory Distress Syndrome. Therefore, additional treatment strategies including the use of the prone position and the use of nitric oxide and prostacyclin nebulisers have been included. The strategies presented in this article are relevant to both critical care nurses and those re-deployed to intensive care units where nurses will inevitably be involved in the management of patients requiring invasive ventilation. Weaning these patients off invasive ventilation is multi-factorial and may be short or long term. A multi-disciplinary weaning plan, the principles, stages/phases, and speed of weaning with expected parameters prior extubation are explained. Planned and unplanned extubation with the serious complications of the latter as the patient may not be ready and may require emergency re-intubation resulting in setbacks should be avoided.

Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.

Dispelling Myths and Unfounded Practices About Enteral Nutrition

Many protocols and steps in the process of enteral nutrition (EN) use are not overly supported with strong research and have been done the same way over many years without questioning the use of best-practices evidence. This article reports many of the myths and unfounded practices surrounding EN and attempts to refute those myths with current evidence. These practices include those about enteral access devices, formulas, enteral administration, and complications.

Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position

Aim

To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS).

Methods

Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients' demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded.

Results

Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position.

Conclusion

In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Enteral Nutrition in the Mechanically Ventilated Patient

Mechanically ventilated patients are unable to take food orally and therefore are dependent on enteral nutrition for provision of both energy and protein requirements. Enteral nutrition is supportive therapy and may impact patient outcomes in the intensive care unit. Early enteral nutrition has been shown to decrease complications and hospital length of stay and improve the prognosis at discharge. Nutrition support is unique for patients on mechanical ventilation and, as recently published literature shows, should be tailored to the individuals' underlying pathology. This review will discuss the most current literature and recommendations for enteral nutrition in patients receiving mechanical ventilation.

Analysis of complications of prone position in acute respiratory distress syndrome: Quality standard, incidence and related factors

Introduction

The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis.

Objectives

To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications.

To identify the incidence of serious complications registered as well as to identify possible factors related to these complications.

Method

Retrospective, cross-sectional descriptive study, polyvalent ICU (16 beds).

Study population

Patients with acute respiratory distress syndrome treated with PP (January 2012–December 2013).

Study variables

PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant.

Results

The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases.

DU were the only serious complication recorded, with a 25.7% incidence.

Possible factors related to DU: more hours in PP in patients developing DU (p = 0.067). Less incidence of DU in well-nourished patients (p = 0.577).

82.9% of patients were not appropriately nourished.

Conclusions

The percentage of records duly completed is very high. The presence of DU (grade 1–2 mostly) is to be noted. There is no statistical significance, although a trend is obsersed, between DU and hours in PP.

Analysis of complications of prone position in acute respiratory distress syndrome: quality standard, incidence and related factors

INTRODUCTION

The monitoring system based on standards of quality allows clinicians to evaluate and improve the patient's care. According to the quality indicators recommended by Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias, and due to the importance of prone position (PP) as a treatment in patients with acute respiratory distress syndrome, it is fundamental to keep accurate record of serious adverse events occurring during the prone position procedure and its posterior analysis.

OBJECTIVES

To establish fulfilment of the Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias standards of quality according to the register of serious complications. To identify the incidence of serious complications registered as well as to identify possible factors related to these complications.

METHOD

Retrospective, cross-sectionsl descriptive study, polyvalent ICU (16 beds). Study population Patients with acute respiratory distress syndrome treated with PP (January 2012-December 2013). Study variables PP recording, accidental extubation, removal of catheters, decubitus ulcers (DU), ETT obstruction, urgency of the procedure, hours in PP, nutritional intake, type of feeding tube, food regurgitation/retention and use of prokinetics/muscle relaxant.

RESULTS

The study sample comprised 38 cases, with an adequate record of complications in 92.1% of the cases. DU were the only serious complication recorded, with a 25.7% incidence. Possible factors related to DU: more hours in PP in patients developing DU (p= .067). Less incidence of DU in well-nourished patients (p= .577). 82.9% of patients were not appropriately nourished.

CONCLUSIONS

The percentage of records duly completed is very high. The presence of DU (grade 1-2 mostly) is to be noted. There is no stastistical significance, although a trend is obversed, between DU and hours in PP.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Purpose

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

Methods

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

Results

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

Conclusions

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.

Aspiration and the Risk of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is a major concern in the intensive care unit. It is estimated that the risk of developing VAP may be as high as 1% per ventilated day, and the attributable mortality approaches 50% in some series. A growing body of evidence implicates the role of microaspiration of contaminated oropharyngeal and perhaps gastroesophageal secretions into the airways as an integral step in the pathogenesis of VAP. In patients who have been intubated and mechanically ventilated for >72 hours, the majority of VAP is caused by enteric gram-negative organisms, presumably of gastrointestinal origin. As a result, strategies designed to minimize the risk of these contaminated secretions into the normally sterile airways are of paramount importance in terms of VAP prevention. This review highlights the important etiological role of the gut in the development of VAP and also discusses the evidence behind interventions that may modulate the risk of both aspiration and subsequent VAP.

Good practices for prone positioning at the bedside: Construction of a care protocol

Last year, interest in prone positioning to treat acute respiratory distress syndrome (ARDS) resurfaced with the demonstration of a reduction in mortality by a large randomized clinical trial. Reports in the literature suggest that the incidence of adverse events is significantly reduced with a team trained and experienced in the process. The objective of this review is to revisit the current evidence in the literature, discuss and propose the construction of a protocol of care for these patients. A search was performed on the main electronic databases: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used in daily practice, with properly trained staff and a well established care protocol are essencial.

Treatment of ARDS With Prone Positioning

Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. This work elucidated the physiological mechanisms underlying changes in gas exchange and respiratory mechanics with prone ventilation. However, translating physiological improvements into a clinical benefit has proved challenging; several contemporary trials showed no major clinical benefits with prone positioning. By optimizing patient selection and treatment protocols, the recent Proning Severe ARDS Patients (PROSEVA) trial demonstrated a significant mortality benefit with prone ventilation. This trial, and subsequent meta-analyses, support the role of prone positioning as an effective therapy to reduce mortality in severe ARDS, particularly when applied early with other lung-protective strategies. This review discusses the physiological principles, clinical evidence, and practical application of prone ventilation in ARDS.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Enteral nutrition therapy in critical care : Current knowledge, controversies, and practical implementation]

Nutrition therapy is a cornerstone in critical care. Early enteral feeding in patients who are unable to meet caloric requirements from oral intake is associated with better clinical outcomes. However, there are still uncertainties about optimal timing, dose, and formula selection of enteral nutrition in critically ill patients. In the present article, an overview of current knowledge and practical strategies for successful implementation of enteral nutrition in intensive care patients is given.

Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

Background

Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock.

Methods/Design

The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs.

Discussion

The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015.

Trial registration

ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position

BACKGROUND

Patients treated with mechanical ventilation in the prone position (PP) could have an increased risk for feeding intolerance. However, the available evidence supporting this hypothesis is limited and contradictory.

OBJECTIVE

To examine the feasibility and efficacy of enteral nutrition (EN) support and its associated complications in patients receiving mechanical ventilation in PP.

METHODS

Prospective observational study including 34 mechanically ventilated intensive care patients who were turned to the prone position over a 3-year period. End points related to efficacy and safety of EN support were studied.

RESULTS

In total, more than 1200 patients were admitted to the intensive care unit over a period of 3 years. Of these, 34 received mechanical ventilation in PP. The mean days under EN were 24.7 ± 12.3. Mean days under EN in the supine position were significantly higher than in PP (21.1 vs 3.6; P < .001), but there were no significant differences in gastric residual volume adjusted per day of EN (126.6 vs 189.2; P = .054) as well as diet volume ratio (94.1% vs 92.8%; P = .21). No significant differences in high gastric residual events per day of EN (0.06 vs 0.09; P = .39), vomiting per day of EN (0.016 vs 0.03; P = .53), or diet regurgitation per day of EN (0 vs 0.04; P = .051) were found.

CONCLUSIONS

EN in critically ill patients with severe hypoxemia receiving mechanical ventilation in PP is feasible, safe, and not associated with an increased risk of gastrointestinal complications. Larger studies are needed to confirm these findings.

Definition, prevalence, and outcome of feeding intolerance in intensive care: a systematic review and meta-analysis

Clinicians and researchers frequently use the phrase 'feeding intolerance' (FI) as a descriptive term in enterally fed critically ill patients. We aimed to: (1) determine what is the most accepted definition of FI; (2) estimate the prevalence of FI; and (3) evaluate whether FI is associated with important outcomes. Systematic searches of peer-reviewed publications using PubMed, MEDLINE, and Web of Science were performed with studies reporting FI extracted. We identified 72 studies defining FI. In 33 studies, the definition was based on large gastric residual volumes (GRVs) together with other gastrointestinal symptoms, while 30 studies relied solely on large GRVs, six studies used inadequate delivery of enteral nutrition (EN) as a threshold, and three studies gastrointestinal symptoms without reference to GRV. The median volume used to define a 'large' GRV was 250 ml (ranges from 75 to 500 ml). The pooled proportion (n = 31 studies) of FI was 38.3% (95% CI 30.7-46.2). Five studies reported outcomes, all of them observed adverse outcome in FI patients. In three studies, respectively, FI was associated with increased mortality and ICU length-of-stay. In summary, FI is inconsistently defined but appears to occur frequently. There are preliminary data indicating that FI is associated with adverse outcomes. A standard definition of FI is required to determine the accuracy of these preliminary data.

A practical approach to the use of prone therapy in acute respiratory distress syndrome

In this article we propose a practical approach to the use of prone therapy for acute respiratory distress syndrome (ARDS). We have attempted to provide information to improve the understanding and implementation of prone therapy based on the literature available and our own experience. We review the basic physiology behind ARDS and the theoretical mechanism by which prone therapy can be of benefit. The findings of the most significant studies regarding prone therapy in ARDS as they pertain to its implementation are summarized. Also provided is a discussion of the nuances of utilizing prone therapy, including potential pitfalls, complications, and contraindications. The specific considerations of prone therapy in open abdomens and traumatic brain injuries are discussed as well. Finally, we supply suggested protocols for the implementation of prone therapy discussing criteria for initiation and cessation of therapy as well as addressing issues such as the use of neuromuscular blockade and nutritional supplementation.