Nutrition and metabolic support for critically ill patients

The Predictive and Prognostic Value of Percentage Change in Calf Circumference in Infants and Children During the First Week of Admission in the Pediatric Intensive Care Unit: A Prospective Cohort Study

Calf circumference (CC) is an easy measure of muscle loss; yet, there are limited studies in children. We aimed to assess the viability of the first-week percent change in CC as a prognostic nutritional marker. Two MUAC (mid-upper arm circumference), CC, and weight measurements were carried out: one on the first day of admission and another on the seventh day. The differences and correlations between their percent changes were examined. The possible association between CC percent change and prolonged length of hospital stay (PLOS) and in-hospital mortality was assessed. Seventy participants were enrolled with a median age of 19.5 months. The median (interquartile range [IQR]) of CC percent change was 0.54 (5.5) with significant correlations between it and each of MUAC and weight percent change (ρ = 0.928, P = .001), (ρ = 0.902, P = .001), respectively. Calf circumference percent changes were significantly more negative in children with PLOS; (P = .004). These changes seem to be viable measures of nutritional status.

Undernutrition at PICU Admission Is Predictor of 60-Day Mortality and PICU Length of Stay in Critically Ill Children

BACKGROUND

There are few studies that assess the role of different nutritional assessment variables at pediatric intensive care unit (PICU) admission in predicting clinical outcomes.

OBJECTIVE

To identify nutritional variables in the first 4 days of PICU stay that predict 60-day mortality and time to discharge alive from the PICU.

DESIGN

Single-center prospective study in Southern Brazil, conducted between July 2013 and February 2016. At PICU admission, children with z scores <-2 for body mass index (BMI)-for-age, mid-upper arm circumference (MUAC)-for-age, and triceps skinfold thickness (TSF)-for-age were considered as undernourished.

PARTICIPANTS/SETTING

There were 199 patients, aged <15 years, with PICU stay >48 hours.

MAIN OUTCOME MEASURES

Sixty-day mortality and time to discharge alive from the PICU.

STATISTICAL ANALYSIS PERFORMED

Cox regression model was applied to determine predictors of 60-day mortality and time to discharge alive from the PICU.

RESULTS

Median age was 23.1 months (interquartile range=3.9 to 89.1), and 63% were male, with 18% prevalence of undernutrition at admission by BMI-for-age. Median PICU stay was 7 days (interquartile range=4 to 12), and 60-day mortality was 12%. After adjusting for sex, age, Pediatric Index of Mortality 2, and presence of complex chronic conditions, undernutrition based on BMI-for-age (hazard ratio [HR]=3.75; 95% CI=1.41 to 9.95; P=0.008), MUAC-for-age (HR=7.62; 95% CI=2.42 to 23.97; P=0.001), and TSF-for-age (HR=4.01; 95% CI=1.14 to 14.15; P=0.031) was associated with higher risk of 60-day mortality. Based on MUAC-for-age with the same adjustment model, undernourished children had longer time to discharge alive from the PICU (HR=0.45; 95% CI=0.21 to 0.98; P=0.045).

CONCLUSIONS

Undernutrition at PICU admission based on different anthropometric variables was predictive of 60-day mortality and longer time to discharge alive from the PICU.

Acute Colonic Pseudo-Obstruction with Feeding Intolerance in Critically Ill Patients: A Study according to Gut Wall Analysis

Objective. To compare the differences between acute colonic pseudo-obstruction (ACPO) with and without acute gut wall thickening. Methods. ACPO patients with feeding tolerance were divided into ACPO with no obvious gut wall thickening (ACPO-NT) group and ACPO with obvious acute gut wall thickening (ACPO-T) group according to computed tomography and abdominal radiographs. Patients' condition, responses to supportive measures, pharmacologic therapy, endoscopic decompression, and surgeries and outcomes were compared. Results. Patients in ACPO-T group had a significantly higher APACHE II (11.82 versus 8.25, p = 0.008) and SOFA scores (6.47 versus 3.54, p < 0.001) and a significantly higher 28-day mortality (17.78% versus 4.16%, p = 0.032) and longer intensive care unit stage (4 versus 16 d, p < 0.001). Patients in ACPO-NT group were more likely to be responsive to supportive treatment (62.50% versus 24.44%, p < 0.001), neostigmine (77.78% versus 17.64%, p < 0.001), and colonoscopic decompression (75% versus 42.86%, p = 0.318) than those in ACPO-T group. Of the patients who underwent ileostomy, 81.25% gained benefits. Conclusions. ACPO patients with gut wall thickening are more severe and are less likely to be responsive to nonsurgical treatment. Ileostomy may be a good option for ACPO patients with gut wall thickening who are irresponsive to nonsurgical treatment.

Comparison of Two Different Enteral Nutrition Protocol in Critically Ill Patients

OBJECTIVE

In this study, two enteral nutrition protocols with different gastric residual volumes (GRVs) and different monitoring intervals were compared with respect to gastrointestinal intolerance findings in intensive care unit (ICU) patients.

METHODS

The study was carried out prospectively in 60 patients in the anaesthesiology and reanimation ICU under mechanical ventilation support, who were scheduled to take enteral feeding. Patients were sequentially divided into two groups: Group 1, GRV threshold of 100 mL, and monitoring interval of 4 hours, and Group 2, GRV threshold of 200 mL, monitoring interval of 8 hours. To test the significant difference between the groups, Student's t test, chi-square text and Fisher exact test were used.

RESULTS

In Group 1, 3.3% vomiting, 6.6% diarrhoea was observed; in Group 2, 16.6% vomiting, 10% diarrhoea. In terms of total intolerance (vomiting and/or diarrhoea) of the two groups, the incidence was significantly higher in Group 2 (33.3%) than in Group 1 (10%) (p=0.02).

CONCLUSION

According to the results of the study, a lower gastrointestinal intolerance rate was detected in the GRV threshold 100 mL, monitoring interval for 4 hours protocol (Group 1) than in GRV threshold 200 mL, monitoring interval for 8 hours protocol (Group 2); Group 1 may be preferred renovation.

Change of serum prealbumin levels and serum protein markers between egg white powder and casein protein additives in standard enteral feeding formulas in critically ill patients with acute respiratory failure

Background

Protein deficiency is a major problem in critically ill patients. Egg white powder recently became a standard additive for protein supplementation in our unit. However, clinical data are not available to support egg white powder supplementation compared to standard protein casein supplementation. This study aimed to determine the change of serum prealbumin (PAB) levels of egg white powder compared to casein additive in standard enteral feeding in critically ill patients with respiratory failure.

Methods

A prospective double-blind, randomized, non-inferiority study was conducted in patients with acute respiratory failure in the medical intensive care unit and respiratory care unit. These patients randomly received 1500 kcal/day of enteral nutrition support with 40 g/day of protein additives by either egg white protein powder or casein protein for 7 days. The serum PAB and C-reactive protein (CRP) levels were measured on days 1, 3, 5, and 7. Repeated-measures ANOVA determined the group effects displayed by serum PAB and CRP levels. p values <0.05 were considered statistically significant.

Results

Thirty-four patients were in two groups: 17 in the casein protein group and 17 in the egg white powder group. The clinical characteristics, baseline nutritional status, and biochemistries were not significantly different between the groups. No statistically significant differences were seen in the serum PAB and serum CRP levels between the two groups. The average mean ± SEM difference of serum PAB level between the groups was 2.3 ± 2.5 mg% (p = 0.58).

Conclusions

The levels of PAB between the egg white protein additive and casein protein additive were not significantly different and less than the non-inferior margin.

Trial registration

Thai Clinical Trials Registry TCTR20160126002