Evidence-based nutritional support in the intensive care unit

Effects of Energy Delivery Guided by Indirect Calorimetry in Critically Ill Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The utility of using indirect calorimetry (IC) to estimate energy needs and methods for its application to this purpose remain unclear. This systematic review investigated whether using IC to estimate energy expenditure in critically ill patients is more meaningful for improving survival than other estimation methods.

METHODS

Comprehensive searches were conducted in MEDLINE using PubMed, Cochrane Central Register of Controlled Trials, and Igaku-Chuo-Zasshi up to March 2023.

RESULTS

Nine RCTs involving 1178 patients were included in the meta-analysis. The evidence obtained suggested that energy delivery by IC improved short-term mortality (risk ratio, 0.86; 95% confidence interval [CI], 0.70 to 1.06). However, the use of IC did not appear to affect the length of ICU stay (mean difference [MD], 0.86; 95% CI, -0.98 to 2.70) or the duration of mechanical ventilation (MD, 0.66; 95% CI, -0.39 to 1.72). Post hoc analyses using short-term mortality as the outcome found no significant difference by target calories in resting energy expenditure, whereas more frequent IC estimates were associated with lower short-term mortality and were more effective in mechanically ventilated patients.

CONCLUSIONS

This updated meta-analysis revealed that the use of IC may improve short-term mortality in patients with critical illness and did not increase adverse events.

Optimal Nutritional Factors Influencing the Duration of Mechanical Ventilation Among Adult Patients with Critical Illnesses in an Intensive Care Unit

Objective

This study aims to identify the impact of nutritional factors on mechanical ventilation duration for critical patients.

Patients and Methods

The current study was a single-center, prospective observational design which enrolled one-hundred critically ill patients who were admitted to an intensive care unit (ICU). It demonstrates purposive sampling and also performs the descriptive nutritional factors influencing the mechanical ventilation duration. Daily calories target requirement scale (DCRS), subjective global assessment form (SGA), dyspnea assessment form, and APACHE II have been used as methods in the study along with time to initial enteral nutrition (EN) after 24-hour admission and daily calories target requirement over 7 days to assess patients. Data is analyzed using the multiple regressions.

Results

As a result, nutritional status monitoring, time to initial EN, calories and target requirements are statistically positive significance associated with the mechanical ventilation duration respectively (R = 0.54, R = 0.30, R= 0.40, p < 0.05). However, age, illness severity, and dyspnea scales are not associated with the mechanical ventilation duration (p> 0.05). Therefore, the nutritional status, malnutrition scores and calorie target requirements can be used to significantly predict the mechanical ventilation duration. The predictive power is 58 and 28.0% of variance. The most proper influencer to predict the mechanical ventilation duration is nutritional status or malnutrition scores.

Conclusion

The research findings show that the nutritional status, time to initial EN, and calorie target requirement within 7 days of admission are associated with the mechanical ventilation duration in the critical patients. Therefore, it can be used to develop guidelines reducing the mechanical ventilation duration and to promote the ventilator halting for critical patients.

Prognostic Performance of NUTRIC Score in Quantifying Malnutrition Risk in the Critically Ill in Congruence With the Bioelectrical Impedance Analysis

BACKGROUND

There is still no concrete guidance for assessing malnutrition risk in the critically ill. Nutrition Risk in the Critically Ill (NUTRIC) score is undertaken cautiously compared with other validated tools such as bioelectrical impedance analysis (BIA). This study aimed to assess the malnutrition risk in the critically ill using NUTRIC score and assess its congruency with the BIA.

METHODS

In this cross-section observational study, intensive care unit (ICU) patients from various etiologies were assessed using the earlier tools in addition to other prognostic markers (Acute Physiologic Assessment and Chronic Health Evaluation II [APACHE II] and Sequential Organ Failure Assessment [SOFA] scores), caloric attainment, and feeding complications.

RESULTS

Of a total 411 assessed patients, 313 (76.2%) were enterally fed, and 318 (77.4%) were mechanically ventilated. Mean age was 60.7 years, and the median of the assessment since admission was the 12th day. Of those enterally fed patients, 57.9% attained the caloric requirements. Both APACHE II and SOFA scores were compatible in ascertaining ICU mortality at a moderate level (17.88 and 7.17, respectively). The NUTRIC score and phase angle (PA) measured by BIA revealed no differences in the malnutrition risk between patients with and without enteral nutrition. However, regression indicated that the NUTRIC score has explained only 1.1% of the variance of PA after controlling other covariates (β = -0.222, P = .009, confidence interval = -0.31 to -0.05).

CONCLUSIONS

NUTRIC score has a limited prediction to the urgency of aggressive nutrition therapy within the early period of ICU admission.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

BACKGROUND AND PURPOSE

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.

METHODS

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.

RESULTS

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.

CONCLUSIONS

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and Purpose

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version.

Methods

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members.

Results

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.

Conclusions

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

Enteral nutrition in the prevention and treatment of pressure ulcers in adult critical care patients

Prevention and healing of pressure ulcers in critically ill patients can be especially challenging because of the patients' burden of illness and degree of physiological compromise. Providing adequate nutrition may help halt the development or worsening of pressure ulcers. Optimization of nutrition can be considered an essential ingredient in prevention and healing of pressure ulcers. Understanding malnutrition in critical care patients, the effect of nutrition on wound healing, and the application of evidence-based nutritional guidelines are important aspects for patients at high risk for pressure ulcers. Appropriate screenings for nutritional status and risk for pressure ulcers, early collaboration with a registered dietician, and administration of appropriate feeding formulations and micronutrient and macronutrient supplementation to promote wound healing are practical solutions to improve the nutritional status of critical care patients. Use of nutritional management and enteral feeding protocols may provide vital elements to augment nutrition and ultimately result in improved clinical outcomes.

Malnutrition in the ICU patient population

Malnutrition has been identified as a cause for disease as well as a condition resulting from inflammation associated with acute or chronic disease. Malnutrition is common in acute-care settings, occurring in 30% to 50% of hospitalized patients. Inflammation has been associated with malnutrition and malnutrition has been associated with compromised immune status, infection, and increased intensive care unit (ICU) and hospital length of stay. The ICU nurse is in the best position to advocate for appropriate nutritional therapies and facilitate the safe delivery of nutrition.

Dietary and pharmacological management of severe catabolic conditions

INTRODUCTION

Nutritional debilitation is among the most devastating and life-threatening complications of cancers and various chronic diseases. It arises from a complex interaction between the illness and the host. This process includes cytokine production, release of lipid-mobilizing and proteolysis-inducing agents and alterations in intermediary metabolism. As a result, many patients develop cachexia with progressive body fat and muscle tissue wasting with associated worsening of their clinical status and a lower quality of life. This review will provide up-to-date information about different pharmacological management of cachexia.

FINDINGS

Until recently, the 2 major options for pharmacological therapy have been either progestational agents or corticosteroids. However, knowledge of the mechanisms of cachexia has led to newer therapeutic interventions for treating several aspects of the syndrome. These include antiserotonergic agents, branched-chain amino acids, eicosapentanoic acid, melanocortin antagonists and antimyostatin agents-all of which act on the feeding-regulatory circuitry to increase appetite and inhibit illness-derived catabolic elements.

CONCLUSIONS

Information from this review will guide health care providers in limiting weight loss and improve performance status of the cachectic patients through dietary and pharmacological therapy, with the hope that such approach would extend patients survival and improve their quality of life.

Skin integrity in critically ill obese patients

Almost one-third of intensive care unit (ICU) patients are obese. Obese patients pose a unique challenge for preventing skin breakdown, healing wounds, and preventing complications of surgery and prolonged immobility. Yet little research to date has been done to study the effects of obesity on skin integrity and wound healing in this patient population. This article discusses common skin conditions and wound complications associated with obese patients and general treatment guidelines as they pertain to the critically ill patient.