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Parisi J, Martínez de Lagran I, Serra-Prat M, Roca Fontbona M, Merino R, de la Torre MªC, Campins L, Yébenes JC. Validation of the nutritrauma concept for the detection of potential harmful effects of medical nutritional treatment in critically ill patients in real life. NUTR HOSP 2024; 41:743-751. [PMID: 38804970 DOI: 10.20960/nh.04993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Introduction Introduction: medical nutritional treatment (MNT) can be complex and may be associated with potential metabolic complications, which has been recently described as nutritrauma. Objective: the aim of our work is to describe whether the application of the nutritrauma concept in real life is feasible and useful to detect the metabolic complications associated with the prescription of MNT. Material and methods: in this descriptive, prospective study at a single center we enrolled 30 consecutive critically ill patients in a 14-bed medical-surgical intensive care unit. The nutritrauma strategy implementation was based in four "M" steps: Metabolic screening, MNT prescription, biochemical Monitoring, and nutritional Management. Results: we analyzed 28 patients (mean age, 69.7 ± 11.3 years; APACHE II, 18.1 ± 8.1; SOFA, 7.5 ± 3.7; Nutric Score, modified, 4.3 ± 2.01, and mean BMI, 27.2 ± 3.8). The main cause of admission was sepsis (46.4 %). Length of ICU stay was 20.6 ± 15.1 days; 39.3 % of subjects died during their ICU stay. Enteral nutrition (82.1 %) was more frequent than parenteral nutrition (17.9 %). During nutritional monitoring, 54 specific laboratory determinations were made. Hyperglycemia was the most frequent metabolic alteration (83.3 % of measurements). Electrolyte disturbances included hypocalcemia (50 %), hypophosphatemia (29.6 %) and hypokalemia (27.8 %). The most frequent lipid profile abnormalities were hypocholesterolemia (64.8 %) and hypertriglyceridemia (27.8 %). Furthermore, nutritional prescription was modified for 53.6 % of patients: increased protein dosage (25 %), increased calorie dosage (21.4 %) and change to organ-specific diet (17.8 %). Conclusions: in conclusion, the application of the nutritrauma approach facilitates detection of metabolic complications and an evaluation of the appropriate prescription of MNT.
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Affiliation(s)
- Jordi Parisi
- Department of Intensive Medicine. Hospital de Mataró
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Melchers M, Kouw IWK, Arabi YM, Casaer MP, Cotoia A, Gunst J, Malbrain MLNG, Schaller SJ, Starkopf J, Rehal MS, Blaser AR, van Zanten ARH. Prospective multicenter study to describe the prevalence, outcomes, and management of phosphate disorders in intensive care patients: Study protocol for part B of the international GUTPHOS study. Clin Nutr ESPEN 2024; 63:681-687. [PMID: 39069259 DOI: 10.1016/j.clnesp.2024.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Aberrations in blood phosphate (Pi) levels, whether presenting as hypo- or hyperphosphatemia, appear to be associated with clinical complications and adverse outcomes in patients admitted to an intensive care unit (ICU). However, the prevalence of Pi disorders and the association with subsequent factors and organ failures leading to death in ICU patients are poorly described. Despite endeavors to understand the etiology and treatment of low Pi levels from systematic reviews and meta-analyses, the literature lacks comprehensive guidance for managing hypophosphatemia. Hyperphosphatemia, on the other hand, appears to be associated with higher mortality among critically ill patients, yet its prevalence among ICU patients, particularly following phosphate repletion, remains unknown. The present study aims to investigate the prevalence of Pi abnormalities upon ICU admission and their incidence during the first week of ICU stay, the factors associated with Pi alterations, and the effect of phosphate repletion on the normalization of Pi levels, and its associations with clinical outcomes. METHODS This multicentre, prospective, non-interventional cohort study will include at least 1000 consecutive adult ICU patients (≥18 years) as part B of the GUTPHOS study. Sites are eligible if an anticipated minimal inclusion of 50 eligible patients during eight weeks from January 2024 until June 2024 and daily phosphate measurements during the first seven days of ICU stay are expected. All consecutive adult patients admitted to a participating ICU during the recruitment period, lasting up to eight weeks, or up to 120 patients if enrollment reaches that limit earlier, will be included. Study parameters include study site characteristics, patient demographics, daily assessment of Pi levels, Pi-related treatment, feeding details, renal replacement therapy details, the incidence of refeeding-associated hypophosphatemia and administered medication (during the first seven calendar days of ICU stay). There will be a follow-up period of a maximum of 90 days to document 28- and 90-day all-cause mortality as the primary outcome. Multiple logistic regression will be used to assess independent associations with mortality in addition to Receiver Operating Characteristics curves to identify cut-off Pi values associated with mortality and overcorrection. Linear mixed models will be conducted to assess Pi treatment effects. Subgroup analyses will be performed based on Pi abnormalities observed during ICU admission, categorized as normo-, hypo-, hyper-, or mixed, along with its severity (mild, moderate, or severe). DISCUSSION The GUTPHOS study will be the first multicentre, prospective observational cohort study to investigate the prevalence, management practices, and consequent outcomes associated with Pi abnormalities during the first week of ICU admission. Its results may bridge the current evidence gap in repletion protocols while establishing the groundwork for a subsequent randomized controlled trial. CLINICAL TRIAL REGISTRY NCT05909722.
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Affiliation(s)
- Max Melchers
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
| | - Imre W K Kouw
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium.
| | - Antonella Cotoia
- Department of Anesthesia and Intensive Care, University Hospital Policlinico of Foggia, Foggia, Italy.
| | - Jan Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium.
| | - Manu L N G Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland; Medical Data Management (Medaman), Geel, Belgium.
| | - Stefan J Schaller
- Department of Anesthesiology and Intensive Care Medicine (CCM/CKV), Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Anesthesiology and Intensive Care, School of Medicine and Health, Technical University of Munich, Munich, Germany.
| | - Joel Starkopf
- Department of Anesthesiology and Intensive Care, University of Tartu, Estonia.
| | - Martin Sundström Rehal
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden; Division of Anaesthesia and Intensive Care, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.
| | - Annika Reintam Blaser
- Department of Anesthesiology and Intensive Care, University of Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
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Tongyoo S, Rawangban P, Naorungroj T. Prevalence, predictive factors, and outcomes of refeeding syndrome among medically critically ill patients: A retrospective cohort study. Nutr Clin Pract 2024. [PMID: 38864503 DOI: 10.1002/ncp.11160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Refeeding syndrome (RFS) is a life-threatening metabolic derangement occurring when nutrition is reintroduced after prolonged starvation. Limited data exist regarding RFS prevalence, risk factors, and outcome, particularly in critically ill patients. METHODS A retrospective cohort study was conducted in a medical intensive care unit from June 2018 to August 2020. RFS diagnostic criteria from the National Institute for Health and Care Excellence (NICE) and the American Society for Parenteral and Enteral Nutrition (ASPEN) were used. The primary outcome was 30-day mortality. RESULTS Among 216 patients, RFS was diagnosed in 22.7% and 27.3% of patients per the NICE and ASPEN criteria, respectively. There was no significant difference in 30-day mortality between patients with and without RFS (22/59 [37.3%] vs 53/157 [33.8%]; P = 0.627). Independent predictors of RFS were malignancy (odds ratio [OR] = 2.09; 95% CI = 1.06-4.15; P = 0.035), septic shock (OR = 2.26; 95% CI = 1.17-4.39; P = 0.016), and high NICE RFS risk classification (OR = 2.52; 95% CI = 1.20-5.31; P = 0.015). Factors associated with reduced RFS risk were Sequential Organ Failure Assessment (SOFA) scores >12 (OR = 0.45; 95% CI = 0.23-0.88; P = 0.020) and high-dose vasopressor treatment (OR = 0.34; 95% CI = 0.14-0.79; P = 0.012). CONCLUSION RFS affected one-fourth of the critically ill patients but did not significantly impact 30-day mortality. Malignancy, septic shock, and high NICE RFS risk classification were positively associated with RFS, whereas high SOFA scores and extensive vasopressor use were linked to decreased risk.
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Affiliation(s)
- Surat Tongyoo
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pratya Rawangban
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thummaporn Naorungroj
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Guan X, Chen D, Xu Y. Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China. JOURNAL OF INTENSIVE MEDICINE 2024; 4:137-159. [PMID: 38681796 PMCID: PMC11043647 DOI: 10.1016/j.jointm.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 05/01/2024]
Abstract
The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.
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Affiliation(s)
- Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, Beijing, China
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Yasuda H, Horikoshi Y, Kamoshita S, Kuroda A, Moriya T. Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database. Nutrients 2023; 16:57. [PMID: 38201887 PMCID: PMC10781052 DOI: 10.3390/nu16010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Some critically ill patients completely rely on parenteral nutrition (PN), which often cannot provide sufficient energy/amino acids. We investigated the relationship between PN doses of energy/amino acids and clinical outcomes in a retrospective cohort study using a medical claims database (≥10.5 years, from Japan, and involving 20,773 adult intensive care unit (ICU) patients on mechanical ventilation and exclusively receiving PN). Study patients: >70 years old, 63.0%; male, 63.3%; and BMI < 22.5, 56.3%. Initiation of PN: third day of ICU admission. PN duration: 12 days. In-hospital mortality: 42.5%. Patients were divided into nine subgroups based on combinations of the mean daily doses received during ICU days 4-7: (1) energy (very low <10 kcal/kg/day; low ≥10, <20; and moderate ≥20); (2) amino acids (very low <0.3 g/kg/day; low ≥0.3, <0.6; and moderate ≥0.6). For each subgroup, adjusted odds ratios (AORs) of in-hospital mortality with 95% confidence intervals (CIs) were calculated by regression analysis. The highest odds of mortality among the nine subgroups was in the moderate calorie/very low amino acid (AOR = 2.25, 95% CI 1.76-2.87) and moderate calorie/low amino acid (AOR = 1.68, 95% CI 1.36-2.08) subgroups, meaning a significant increase in the odds of mortality by between 68% and 125% when an amino acid dose of <0.6 g/kg/day was prescribed during ICU days 4-7, even when ≥20 kcal/kg/day of calories was prescribed. In conclusion, PN-dependent critically ill patients may have better outcomes including in-hospital mortality when ≥0.6 g/kg/day of amino acids is prescribed.
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Affiliation(s)
- Hideto Yasuda
- Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Ohmiya-ku, Saitama 330-0834, Japan;
| | - Yuri Horikoshi
- Medical Affairs Department, Research and Development Center, Otsuka Pharmaceutical Factory, Inc., 2-9 Kandatsukasa-machi, Chiyoda-ku, Tokyo 101-0048, Japan; (Y.H.); (S.K.)
| | - Satoru Kamoshita
- Medical Affairs Department, Research and Development Center, Otsuka Pharmaceutical Factory, Inc., 2-9 Kandatsukasa-machi, Chiyoda-ku, Tokyo 101-0048, Japan; (Y.H.); (S.K.)
| | - Akiyoshi Kuroda
- Research and Development Center, Otsuka Pharmaceutical Factory, Inc., 2-9 Kandatsukasa-machi, Chiyoda-ku, Tokyo 101-0048, Japan;
| | - Takashi Moriya
- Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Ohmiya-ku, Saitama 330-0834, Japan;
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Dock-Nascimento DB, Ribeiro AC, Silva Junior JM, de Aguilar-Nascimento JE. Impact of Nutritional Management on Survival of Critically Ill Malnourished Patients with Refeeding Hypophosphatemia. Arch Med Res 2023; 54:231-238. [PMID: 36805190 DOI: 10.1016/j.arcmed.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early nutritional therapy may aggravate hypophosphatemia in critically ill patients. AIM To investigate the influence of the type nutritional therapy on the survival of critically-ill malnourished patients at refeeding hypophosphatemia risk. METHODS Retrospective cohort study including malnourished, critically-ill adults, admitted from June 2014-December 2017 in an intensive care unit (ICU) at a tertiary hospital. Refeeding hypophosphatemia risk was defined as low serum phosphorus levels (<2.5 mg/dL) seen at two timepoints: before the initiation and at day 4 of the nutritional therapy. Patients receiving enteral nutrition (EN) were compared with those receiving supplemental parenteral nutrition (SPN-EN plus parenteral nutrition). Primary outcome was 60 d survival. Secondary endpoint was the incidence of refeeding hypophosphatemia risk. RESULTS We included 468-321 patients (68.6%) received EN and 147 (31.4%) received SPN. The mortality rate was 36.3% (n = 170). Refeeding hypophosphatemia risk was found in 116 (24.8%) patients before and in 177 (37.8%) at day 4 of nutritional therapy. The 60 d mean survival probability was greater for patients receiving SPN both before (42.4 vs. 22.4%, p = 0.005) and at day 4 (37.4 vs. 25.8%, p = 0.014) vs. patients receiving EN at the same timepoints. Cox regression showed a hazard ratio of 3.3 and 2.4 for patients at refeeding hypophosphatemia risk before and at day 4 of EN, respectively, compared to the SPN group at the same timepoints. CONCLUSION Refeeding hypophosphatemia risk was frequent in malnourished ICU patients and the survival for patients receiving SPN seemed associated with better survival than EN only.
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Affiliation(s)
| | - Amanda Coelho Ribeiro
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil
| | - João Manoel Silva Junior
- Postgraduate Program in Anesthesiology of University of São Paulo, Brazil; Anesthesiology Department of Hospital do Servidor Publico Estadual, São Paulo, Brazil
| | - José Eduardo de Aguilar-Nascimento
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil; University Center of Várzea Grande Medical School, Cuiabá, Brazil.
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Zhang W, Zhang SX, Chen SF, Yu T, Tang Y. Development and validation of risk prediction model for refeeding syndrome in neurocritical patients. Front Nutr 2023; 10:1083483. [PMID: 36875840 PMCID: PMC9975392 DOI: 10.3389/fnut.2023.1083483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
Background The incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. However, the current status and risk factors for the occurrence of RFS in neurocritical patients remain unclear. Elucidating these aspects may provide a theoretical basis for screening populations at high risk of RFS. Methods A total of 357 patients from January 2021 to May 2022 in a neurosurgery ICU of a tertiary hospital in China were included using convenience sampling. Patients were divided into RFS and non-RFS groups, based on the occurrence of refeeding-associated hypophosphatemia. Risk factors for RFS were determined using univariate and logistic regression analyses, and a risk prediction model for RFS in neurocritical patients was developed. The Hosmer-Lemeshow test was used to determine the goodness of fit of the model, and the receiver operator characteristic curve was used to examine its discriminant validity. Results The incidence of RFS in neurocritical patients receiving enteral nutrition was 28.57%. Logistic regression analyses showed that history of alcoholism, fasting hours, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores, low serum albumin, and low baseline serum potassium were risk factors of RFS in neurocritical patients (p < 0.05). The Hosmer-Lemeshow test showed p = 0.616, and the area under the ROC curve was 0.791 (95% confidence interval: 0.745-0.832). The optimal critical value was 0.299, the sensitivity was 74.4%, the specificity was 77.7%, and the Youden index was 0.492. Conclusion The incidence of RFS in neurocritical patients was high, and the risk factors were diverse. The risk prediction model in this study had good predictive effects and clinical utility, which may provide a reference for assessing and screening for RFS risk in neurocritical patients.
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Affiliation(s)
- Wei Zhang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Sheng-Xiang Zhang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shu-Fan Chen
- Department of Nursing, Soochow University, Suzhou, China
| | - Tao Yu
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yun Tang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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8
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Yang YJ, Su S, Zhang Y, Wu D, Wang C, Wei Y, Peng X. Effects of enteral nutrition with different energy supplies on metabolic changes and organ damage in burned rats. BURNS & TRAUMA 2022; 10:tkac042. [PMID: 36420355 PMCID: PMC9678637 DOI: 10.1093/burnst/tkac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Enteral nutrition (EN) is an important treatment for burn patients. However, severe gastrointestinal damage caused by major burns often leads to EN intolerance. Trophic EN solves this problem basically, but how to transition from trophic EN to standard EN smoothly is still a challenge in burn clinical nutrition. The aim of this study is to investigate the effects of EN with different energy supplies on metabolic changes, organ damage and prognosis in burned rats. METHODS Different feeding regimens were designed based on the continuous monitoring of resting energy expenditure in rats. Thirty-two Sprague-Dawley rats were randomly divided into a normal control group, burn +50% REE group, burn +75% REE group and burn +100% REE group. At the end of a nutritional treatment cycle (14th day), nuclear magnetic resonance spectroscopy, blood biochemistry analysis and quantification of subscab bacteria were performed to explore the differences in metabolic changes, degrees of organ damage and prognoses between the groups. RESULTS Sixteen metabolites involving seven metabolic pathways were identified from the different energy supply groups. After burn injury, resting energy consumption and body weight loss increased obviously. Meanwhile, weight loss was inversely related to energy supply. The greatest changes in the degree of organ damage, the level of plasma proteins, lipids and endotoxins, as well as the quantification of subscab bacteria were observed in the 50% REE group, followed by the 75 and 100% groups. CONCLUSIONS Achieving an early balance between energy supply and expenditure is conducive to mitigating metabolic disorders and improving prognosis after burn injury.
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Affiliation(s)
| | | | | | - Dan Wu
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Chao Wang
- Institute of Burn Research, State Key Laboratory of Trauma, Burns and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
| | - Yan Wei
- Clinical Medical Research Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing China
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Preiser JC, Arabi YM, Berger MM, Casaer M, McClave S, Montejo-González JC, Peake S, Reintam Blaser A, Van den Berghe G, van Zanten A, Wernerman J, Wischmeyer P. A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice. Crit Care 2021; 25:424. [PMID: 34906215 PMCID: PMC8669237 DOI: 10.1186/s13054-021-03847-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/27/2021] [Indexed: 12/15/2022] Open
Abstract
The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.
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Affiliation(s)
- Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium.
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mette M Berger
- Adult Intensive Care, Lausanne University Hospital, CHUV, 1011, Lausanne, Switzerland
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stephen McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Juan C Montejo-González
- Intensive Care Medicine, Hospital Universitario, 12 de Octubre, Instituto de Investigación imas12, Madrid, Spain
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, Australia.,Department of Critical Care Research, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arthur van Zanten
- Ede and Division of Human Nutrition and Health, Gelderse Vallei Hospital, Wageningen University and Research, Wageningen, The Netherlands
| | - Jan Wernerman
- Division of Anaesthesiology and Intensive Care Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, NC, USA
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Chen Z, Gao C, Yu H, Lu L, Liu J, Chen W, Xiang X, Hussain HMJ, Lee BJ, Li C, Wei W, Huang Y, Li X, Fang Z, Yu S, Weng Q, Ouyang Y, Hu X, Tong J, Liu J, Lin L, Liu M, Xu X, Liu D, Song Y, Lv X, Zha Y, Ye Z, Jiang T, Jia J, Chen X, Bi Y, Xue J, Chen N, Hu W, He CJ, Wang H, Liu J, Xie J. Hypophosphatemia is an independent risk factor for AKI among hospitalized patients with COVID-19 infection. Ren Fail 2021; 43:1329-1337. [PMID: 34541999 PMCID: PMC8462927 DOI: 10.1080/0886022x.2021.1979039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This study sought to investigate incidence and risk factors for acute kidney injury (AKI) in hospitalized COVID-19. METHODS In this retrospective study, we enrolled 823 COVID-19 patients with at least two evaluations of renal function during hospitalization from four hospitals in Wuhan, China between February 2020 and April 2020. Clinical and laboratory parameters at the time of admission and follow-up data were recorded. Systemic renal tubular dysfunction was evaluated via 24-h urine collections in a subgroup of 55 patients. RESULTS In total, 823 patients were enrolled (50.5% male) with a mean age of 60.9 ± 14.9 years. AKI occurred in 38 (40.9%) ICU cases but only 6 (0.8%) non-ICU cases. Using forward stepwise Cox regression analysis, we found eight independent risk factors for AKI including decreased platelet level, lower albumin level, lower phosphorus level, higher level of lactate dehydrogenase (LDH), procalcitonin, C-reactive protein (CRP), urea, and prothrombin time (PT) on admission. For every 0.1 mmol/L decreases in serum phosphorus level, patients had a 1.34-fold (95% CI 1.14-1.58) increased risk of AKI. Patients with hypophosphatemia were likely to be older and with lower lymphocyte count, lower serum albumin level, lower uric acid, higher LDH, and higher CRP. Furthermore, serum phosphorus level was positively correlated with phosphate tubular maximum per volume of filtrate (TmP/GFR) (Pearson r = 0.66, p < .001) in subgroup analysis, indicating renal phosphate loss via proximal renal tubular dysfunction. CONCLUSION The AKI incidence was very low in non-ICU patients as compared to ICU patients. Hypophosphatemia is an independent risk factor for AKI in patients hospitalized for COVID-19 infection.
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Affiliation(s)
- Zijin Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Chenni Gao
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Haijin Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lin Lu
- Department of Nephrology, North Huashan Hospital, Fudan University, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University, School of medicine, Shanghai, China
| | - Wei Chen
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaogang Xiang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hafiz Muhammad Jafar Hussain
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Benjamin J Lee
- Houston Kidney Consultants, Houston, TX, USA.,Houston Methodist Institute for Academic Medicine, Houston, TX, USA
| | - Chuanlei Li
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjie Wei
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yuhan Huang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiang Li
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhengying Fang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Shuwen Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Qinjie Weng
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yan Ouyang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaofan Hu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun Tong
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jian Liu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Li Lin
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | | | - Xiaoman Xu
- Renal Department, Wuhan Ninth Hospital, Wuhan, Hubei, China
| | - Dan Liu
- Radiology Department of Renmin Hospital, Wuhan University, Wuhan, Hubei, China
| | - Yuan Song
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xifeng Lv
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yixin Zha
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyin Ye
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tingting Jiang
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jieshuang Jia
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaonong Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yufang Bi
- Department of Endocrinology and Metabolism disease, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Weiguo Hu
- Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Cijiang John He
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY, USA
| | - Huiming Wang
- Renal Department of Renmin Hospital, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Jun Liu
- Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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11
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Deane AM, Jiang A, Tascone B, Clancy A, Finnis ME, Collie JT, Greaves R, Byrne KM, Fujii T, Douglas JS, Nichol A, Udy AA, Young M, Russo G, Fetterplace K, Maiden MJ, Plummer MP, Yanase F, Bellomo R, Ali Abdelhamid Y. A multicenter randomized clinical trial of pharmacological vitamin B1 administration to critically ill patients who develop hypophosphatemia during enteral nutrition (The THIAMINE 4 HYPOPHOSPHATEMIA trial). Clin Nutr 2021; 40:5047-5052. [PMID: 34388414 DOI: 10.1016/j.clnu.2021.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group. METHOD This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified. RESULTS Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L; P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days; P = 0.37, and deaths 9 (21 %) vs. 5 (11 %); P = 0.25). CONCLUSIONS In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).
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Affiliation(s)
- Adam M Deane
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia.
| | - Alice Jiang
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Brianna Tascone
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Annabelle Clancy
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark E Finnis
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia
| | - Jake T Collie
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia
| | - Ronda Greaves
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia; Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kathleen M Byrne
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Tomoko Fujii
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - James S Douglas
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Alistair Nichol
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Andrew A Udy
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Giovanni Russo
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kate Fetterplace
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew J Maiden
- The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia; Intensive Care Unit, Barwon Health, Geelong, Australia
| | - Mark P Plummer
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
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12
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Zamora-Elson M, Martínez-Carmona JF, Ruiz-Santana S. Recommendations for specialized nutritional-metabolic management of the critical patient: Consequences of malnutrition in the critically ill and assessment of nutritional status. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:19-23. [PMID: 32532406 DOI: 10.1016/j.medin.2020.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/19/2019] [Accepted: 01/11/2020] [Indexed: 01/22/2023]
Affiliation(s)
- M Zamora-Elson
- Hospital Universitario Arnau de Vilanova, Huesca, España.
| | | | - S Ruiz-Santana
- Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, España
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13
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Al Harbi SA, Al-Dorzi HM, Al Meshari AM, Tamim H, Abdukahil SAI, Sadat M, Arabi Y. Association between phosphate disturbances and mortality among critically ill patients with sepsis or septic shock. BMC Pharmacol Toxicol 2021; 22:30. [PMID: 34049590 PMCID: PMC8161900 DOI: 10.1186/s40360-021-00487-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/30/2021] [Indexed: 11/11/2022] Open
Abstract
Objective The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods In this retrospective cohort study, all adult patients who were admitted to the medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, normophosphatemia and hyperphosphatemia based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes. Results Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. The patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required more mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, the hyperphosphatemia group showed significantly higher ICU and hospital mortality in comparison with the other two groups. Conclusion Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.
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Affiliation(s)
- Shmeylan A Al Harbi
- Pharmaceutical Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hasan M Al-Dorzi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Hani Tamim
- Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon
| | - Sheryl Ann I Abdukahil
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. .,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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14
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Reintam Blaser A, van Zanten ARH. Electrolyte disorders during the initiation of nutrition therapy in the ICU. Curr Opin Clin Nutr Metab Care 2021; 24:151-158. [PMID: 33394599 DOI: 10.1097/mco.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition. RECENT FINDINGS Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome. SUMMARY Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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15
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Fiaccadori E, Sabatino A, Barazzoni R, Carrero JJ, Cupisti A, De Waele E, Jonckheer J, Singer P, Cuerda C. ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr 2021; 40:1644-1668. [PMID: 33640205 DOI: 10.1016/j.clnu.2021.01.028] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.
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Affiliation(s)
- Enrico Fiaccadori
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alice Sabatino
- Nephrology Unit, Parma University Hospital, & Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rocco Barazzoni
- Internal Medicine, Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Adamasco Cupisti
- Nephrology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisabeth De Waele
- Intensive Care, University Hospital Brussels (UZB), Department of Nutrition, UZ Brussel, Faculty of Medicine and Pharmacy, Vrije Unversiteit Brussel (VUB), Bruxelles, Belgium
| | | | - Pierre Singer
- General Intensive Care Department and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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16
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Ribeiro AC, Dock-Nascimento DB, Silva JM, Caporossi C, Aguilar-Nascimento JED. Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy. ACTA ACUST UNITED AC 2020; 66:1241-1246. [PMID: 33027452 DOI: 10.1590/1806-9282.66.9.1241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/26/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.
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Affiliation(s)
- Amanda Coelho Ribeiro
- Nutricionista, Mestre em Ciências da Saúde pelo Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - Diana Borges Dock-Nascimento
- Nutricionista, Professor Doutor Associado II, Faculdade de Nutrição da UFMT, Departamento de Alimentos e Nutrição em Cuiabá-MT. Professor orientador do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - João Manoel Silva
- Médico, Professor orientador do Programa de Pós-Graduação em Anestesiologia da Universidade de São Paulo, São Paulo, SP, Brasil.,Componente do corpo clínico do Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - Cervantes Caporossi
- Médico, Professor Doutor do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - José Eduardo de Aguilar-Nascimento
- Médico, Professor Doutor do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil.,Diretor do Curso de Medicina do Centro Universitário de Várzea Grande (Univag), Várzea Grande, MT, Brasil
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17
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Baker T, Ngwalangwa F, Masanjala H, Dube Q, Langton J, Marrone G, Hildenwall H. Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): a pragmatic, randomised controlled trial. LANCET GLOBAL HEALTH 2020; 8:e1546-e1554. [PMID: 33038950 DOI: 10.1016/s2214-109x(20)30388-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/03/2020] [Accepted: 08/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Low blood glucose concentrations are common in sick children who present to hospital in low-resource settings and are associated with increased mortality. The cutoff blood glucose concentration for the diagnosis and treatment of hypoglycaemia currently recommended by WHO (2·5 mmol/L) is not evidence-based. We aimed to assess whether increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely ill children at presentation to hospital improves mortality outcomes. METHODS We did a pragmatic, randomised controlled trial at two referral hospitals in Malawi. Severely ill children aged 1 month to 5 years presenting to the emergency department with a capillary blood glucose concentration of between 2·5 mmol/L (3·0 mmol/L in severely malnourished children) and 5·0 mmol/L were randomly assigned (1:1) by a computer-generated randomisation sequence, stratified by study site and severe malnutrition, to receive either an immediate intravenous bolus of 10% dextrose at 5 mL/kg followed by a 24-h maintenance infusion of 10% dextrose at 100 mL/kg for the first 10 kg of bodyweight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kg of bodyweight (intervention group) or observation for a minimum of 60 min and standard care (control group). Participants and study personnel were not masked to treatment allocation. The primary outcome was all-cause in-hospital mortality, assessed on an intention-to-treat basis. Safety was also assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02989675. FINDINGS Between Dec 5, 2016, and Jan 22, 2019, 10 947 children were screened, of whom 332 were randomly assigned, and 322 were included in the final analysis (n=162 in the control group and n=160 in the intervention group). The study was terminated after an interim analysis at 24% enrolment indicated futility. The median age of participants was 2·3 years (IQR 1·4-3·2), 65 (45%) were female, and the baseline characteristics of participants were similar between the two groups. The number of in-hospital deaths from any cause was 26 (16%) in the control group and 24 (15%) in the intervention group, with an absolute mortality difference of 1·0% (95% CI -6·9 to 9·0). Serious adverse events, including hypoglycaemia, hyperglycaemia, convulsions, reduced consciousness, and death, were reported in 47 (29%) children in the control group and 39 (24%) children in the intervention group. INTERPRETATION Increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely sick children in Malawi from 2·5 mmol/L to 5·0 mmol/L did not reduce all-cause in-hospital mortality. Our findings do not support changing the cutoff for dextrose administration, and further research on the optimal management of severely ill children who present to the emergency department with low blood glucose concentrations is warranted. FUNDING Swedish Research Council and Stockholm Country Council.
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Affiliation(s)
- Tim Baker
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Fatsani Ngwalangwa
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Henderson Masanjala
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi; Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gaetano Marrone
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Helena Hildenwall
- Health System and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi; Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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18
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Di Mario F, Regolisti G, Greco P, Maccari C, Superchi E, Morabito S, Pistolesi V, Fiaccadori E. Prevention of hypomagnesemia in critically ill patients with acute kidney injury on continuous kidney replacement therapy: the role of early supplementation and close monitoring. J Nephrol 2020; 34:1271-1279. [PMID: 33001413 DOI: 10.1007/s40620-020-00864-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
Hypomagnesemia is a common electrolyte disorder in critically ill patients and is associated with increased morbidity and mortality risk. Many clinical conditions may contribute to hypomagnesemia through different pathogenetic mechanisms. In patients with acute kidney injury (AKI) the need for continuous or prolonged intermittent kidney replacement therapy (CKRT and PIKRT, respectively) may further add to other causes of hypomagnesemia, especially when regional citrate anticoagulation (RCA) is used. The basic principle of RCA is chelation of ionized calcium by citrate within the extracorporeal circuit, thus blocking the coagulation cascade. Magnesium, a divalent cation, follows the same fate as calcium; the amount lost in the effluent includes both magnesium-citrate complexes and the free fraction directly diffusing through the hemofilter. While increasing the magnesium content of dialysis/replacement solutions may decrease the risk of hypomagnesemia, the optimal concentration for the variable combination of solutions adopted in different KRT protocols has not yet been identified. An alternative and effective approach is based on including early intravenous magnesium supplementation in the KRT protocol, and close monitoring of serum magnesium levels, especially in the setting of RCA. Thus, strategies aimed at precisely tailoring both dialysis prescriptions and the composition of KRT fluids, as well as early magnesium supplementation and close monitoring, could represent a cornerstone in reducing KRT-related hypomagnesemia.
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Affiliation(s)
- Francesca Di Mario
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy.
| | - Giuseppe Regolisti
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Paolo Greco
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Caterina Maccari
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Eleonora Superchi
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Santo Morabito
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Valentina Pistolesi
- UOSD Dialisi, Azienda Ospedaliero-Universitaria Policlinico Umberto I, "Sapienza" Università̀ di Roma, Rome, Italy
| | - Enrico Fiaccadori
- Dipartimento di Medicina e Chirurgia, UO Nefrologia, Unità Operativa di Nefrologia, Azienda Ospedaliero-Universitaria Parma, Università̀ di Parma, Via Gramsci 14, 43100, Parma, Italy
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19
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Yoshida M, Izawa J, Wakatake H, Saito H, Kawabata C, Matsushima S, Suzuki A, Nagatomi A, Yoshida T, Masui Y, Fujitani S. Mortality associated with new risk classification of developing refeeding syndrome in critically ill patients: A cohort study. Clin Nutr 2020; 40:1207-1213. [PMID: 32828568 DOI: 10.1016/j.clnu.2020.07.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/11/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Although refeeding syndrome (RFS) has been recognized as a potentially fatal metabolic complication, the definition of RFS has remained unclear. Recently, European researchers suggested an evidence-based and consensus-supported algorithm that consisted of a new RFS risk classification and treatment strategies for medical inpatients. The classification was based on the National Institute for Health and Clinical Excellence (NICE) criteria for patients at risk of developing RFS. In this study, we aimed to investigate the frequency of each applied new risk group and the association between the new classification and mortality in critically ill patients. METHODS This cohort study was conducted at a Japanese metropolitan tertiary-care university hospital from December 2016 to December 2018. We included critically ill adult patients who were admitted to the intensive care unit (ICU) via the emergency department and who stayed in the ICU for 24 h or longer. We applied the new risk classification based on the NICE RFS risk factors on ICU admission. The main exposure was risk classification of RFS: no risk, low risk, high risk, or very high risk. The primary outcome was in-hospital mortality censored at day 30 after ICU admission. We performed a multivariable analysis using Cox proportional hazard regression. RESULTS We analyzed 542 patients who met the eligibility criteria. The prevalence of the four RFS risk classification groups was 25.8% for no risk, 25.7% for low risk, 46.5% for high risk, and 2.0% for very high risk. The 30-day mortality was 5.0%, 7.2%, 16.3%, and 27.3%, respectively (log-rank trend test: p < 0.001). In the multivariable Cox regression, adjusted hazard ratios with no risk group as a reference were 1.28 (95% CI 0.48-3.38) for low risk, 2.81 (95% CI 1.24-6.35) for high risk, and 3.17 (95% CI 0.78-12.91) for very high risk. CONCLUSIONS Approximately half the critically ill patients were categorized as high or very high risk based on the new risk classification. Furthermore, as the risk categories progressed, the 30-day in-hospital mortality increased. Early recognition of patients at risk of developing RFS may improve patient outcomes through timely and optimal nutritional treatment.
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Affiliation(s)
- Minoru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Junichi Izawa
- Department of Medicine, Okinawa Prefectural Yaeyama Hospital, 584-1 Maezato, Ishigaki, Okinawa, 907-0002, Japan
| | - Haruaki Wakatake
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Chizu Kawabata
- Department of Nursing, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Shinya Matsushima
- Department of Rehabilitation, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Aya Suzuki
- Department of Nutrition, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Akiyoshi Nagatomi
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Toru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Yoshihiro Masui
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, 1197-1 Yasashicho, Asahi-ku, Yokohama, Kanagawa, 241-0811, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
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20
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Meira APC, Santos COD, Lucho CLC, Kasmirscki C, Silva FM. Refeeding Syndrome in Patients Receiving Parenteral Nutrition Is Not Associated to Mortality or Length of Hospital Stay: A Retrospective Observational Study. Nutr Clin Pract 2020; 36:673-678. [PMID: 32744370 DOI: 10.1002/ncp.10563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Refeeding syndrome (RS) is characterized by severe electrolyte derangement that may be associated with worse clinical outcomes in hospitalized patients. In this study, we aim to assess the incidence of RS in inpatients receiving parenteral nutrition (PN) and its possible association with the length of hospital stay (LHS) and mortality. METHODS We conducted a historical cohort study involving adults receiving PN, monitored by a nutrition therapy team in a Brazilian public hospital. Data collection was made from electronic records. We assessed the presence of RS after PN therapy was initiated. The amount of energy delivered within 72 hours of PN, LHS, and mortality were compared between patients with and without RS. RESULTS One-hundred ninety-seven patients (aged 57.7 ± 14.1 years; 55.7% men) were followed for a median of 51 days. The incidence of RS was equal to 25.4%. The adequacy of energy delivered in relation to energy requirements within 72 hours (69.4% ± 29.3% vs 61.8% ± 21.6%) was higher in patients with RS than in those without RS (P = .054). The incidence of death was 55.3% and did not differ between groups. The median of LHS was equal to 51.0 (32.0-83.0) days, and it also did not differ between patients with and without RS. CONCLUSION RS was identified in 25% of patients receiving PN, but it was not associated to mortality and LHS, even when energy delivery was considered in combination to RS.
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Affiliation(s)
- Ana Paula Corrêa Meira
- Enteral and Parenteral Nutrition Therapy Team in Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | | | | | - Cristine Kasmirscki
- Enteral and Parenteral Nutrition Therapy Team in Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Postgraduate Program in Nutrition Science in Federal University of Health Science of Porto Alegre, Porto Alegre, Brazil
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21
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Ballesteros Sanz MÁ, Hernández-Tejedor A, Estella Á, Jiménez Rivera JJ, González de Molina Ortiz FJ, Sandiumenge Camps A, Vidal Cortés P, de Haro C, Aguilar Alonso E, Bordejé Laguna L, García Sáez I, Bodí M, García Sánchez M, Párraga Ramírez MJ, Alcaraz Peñarrocha RM, Amézaga Menéndez R, Burgueño Laguía P. [Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)]. Med Intensiva 2020; 44:371-388. [PMID: 32360034 PMCID: PMC7142677 DOI: 10.1016/j.medin.2020.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023]
Abstract
On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.
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Affiliation(s)
- M Á Ballesteros Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
| | | | - Á Estella
- Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, España
| | - J J Jiménez Rivera
- Servicio de Medicina Intensiva, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España
| | | | - A Sandiumenge Camps
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - P Vidal Cortés
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, España
| | - C de Haro
- Servicio de Medicina Intensiva, Hospital Universitari Parc Taulí, Sabadell, Barcelona, España; Servicio de Medicina Intensiva, CIBERES Enfermedades Respiratorias, Instituto de Salud Carlos III (ISCIII), Madrid, España
| | - E Aguilar Alonso
- Servicio de Medicina Intensiva, Hospital Infanta Margarita, Cabra, Córdoba, España
| | - L Bordejé Laguna
- Servicio de Medicina Intensiva, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - I García Sáez
- Servicio de Medicina Intensiva, Hospital Universitario Donostia, San Sebastián, España
| | - M Bodí
- Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, Tarragona, España
| | - M García Sánchez
- Servicio de Medicina Intensiva, Hospital Universitario Virgen Macarena, Sevilla, España
| | - M J Párraga Ramírez
- Servicio de Medicina Intensiva, Hospital General Universitario Morales Meseguer, Murcia, España
| | | | - R Amézaga Menéndez
- Servicio de Medicina Intensiva, Hospital Universitari Son Espases, Palma, Islas Baleares, España
| | - P Burgueño Laguía
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
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22
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Ballesteros Sanz M, Hernández-Tejedor A, Estella Á, Jiménez Rivera J, González de Molina Ortiz F, Sandiumenge Camps A, Vidal Cortés P, de Haro C, Aguilar Alonso E, Bordejé Laguna L, García Sáez I, Bodí M, García Sánchez M, Párraga Ramírez M, Alcaraz Peñarrocha R, Amézaga Menéndez R, Burgueño Laguía P. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19). MEDICINA INTENSIVA (ENGLISH EDITION) 2020. [PMCID: PMC7340388 DOI: 10.1016/j.medine.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.
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Drysdale C, Matthews-Rensch K, Young A. Further evidence to throw caution to the wind: outcomes using an assertive approach to manage refeeding syndrome risk. Eur J Clin Nutr 2020; 75:91-98. [PMID: 32623441 DOI: 10.1038/s41430-020-0676-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Refeeding syndrome (RFS) can occur in severely malnourished or starved populations that are provided with rapid or unbalanced nutrition. International guidelines recommend a cautious approach for managing RFS risk (hypocaloric nutrition for 4-7 days), however emerging evidence supports a more assertive approach. This study aimed to describe nutritional management and RFS-related adverse outcomes in patients at risk of RFS receiving care after implementing updated guidelines reflecting emerging evidence. SUBJECTS/METHODS A retrospective cohort study of inpatients at risk of RFS during admission to a large metropolitan hospital in Queensland, Australia between November 2018 and April 2019 was conducted. Data were collected from medical records on nutritional management (provision of nutrition, electrolyte, and vitamin replacement) and outcomes (incidence of RFS, serum electrolyte decreases, hypo/hyperglycaemia, oedema, and organ function disturbance). Data were analysed descriptively; relationships between serum electrolyte decreases and nutrition management were explored using Fisher's Exact tests. RESULTS Of the 70 patients identified at risk of RFS (58.4 ± 16.8 years, 56% male, 94% malnourished), majority of participants received required supplementation prior to the commencement of nutrition (thiamine: 76%; micronutrients: 72-100%; multivitamin: 61%) and a standard initial nutrition management plan (79%; cautious: 13%; liberal: 8%). There were no cases of RFS. Four participants experienced RFS-related adverse outcomes (severe electrolyte decreases: n = 2, hypo/hyperglycaemia: n = 2); however, there was no differences in serum electrolyte decreases based on the nutrition management plan (initial: p = 0.912; goal: p = 0.688). CONCLUSIONS The implementation of more liberal RFS guidelines for the management of RFS risk appears to be safe. Further research examining liberalised refeeding protocols may be useful in updating international guidelines.
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Affiliation(s)
- Candice Drysdale
- The University of Queensland School of Human Movement and Nutrition Sciences, St. Lucia, QLD, Australia.
| | - Kylie Matthews-Rensch
- The University of Queensland School of Human Movement and Nutrition Sciences, St. Lucia, QLD, Australia.,Nutrition and Dietetics Department, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Adrienne Young
- Nutrition and Dietetics Department, The Royal Brisbane and Women's Hospital, Herston, QLD, Australia
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Szeja N, Grosicki S. Refeeding syndrome in hematological cancer patients - current approach. Expert Rev Hematol 2020; 13:201-212. [PMID: 32028807 DOI: 10.1080/17474086.2020.1727738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.
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Affiliation(s)
- Nicola Szeja
- Department of Hematology and Cancer Prevention in Chorzów, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Katowice, Poland
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention in Chorzów, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Katowice, Poland
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25
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McKnight CL, Newberry C, Sarav M, Martindale R, Hurt R, Daley B. Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide. Curr Gastroenterol Rep 2019; 21:58. [PMID: 31758276 DOI: 10.1007/s11894-019-0724-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population. RECENT FINDINGS Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.
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Affiliation(s)
- C L McKnight
- Department of Trauma/Surgical Critical Care, University of Tennessee-Knoxville, 1924 Alcoa Highway Box U-11, Knoxville, TN, 37920, USA.
| | - C Newberry
- Division of Gastroenterology & Hepatology, Weill Cornell Medical Center, 1283 York Avenue, 9th Floor, New York, NY, 10065, USA
| | - M Sarav
- Section of Nephrology and Hypertension, NorthShore University Health Systems, University of Chicago, Chicago, USA
| | - R Martindale
- Department of General Surgery, Oregon Health Science University, 3303 SW Bond Ave Fl 6, Portland, OR, 97239, USA
| | - R Hurt
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - B Daley
- Department of Trauma/Surgical Critical Care, University of Tennessee Graduate School of Medicine, 1924 Alcoa Highway Box U-11, Knoxville, TN, 37920, USA
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Nutritrauma: A Key Concept for Minimising the Harmful Effects of the Administration of Medical Nutrition Therapy. Nutrients 2019; 11:nu11081775. [PMID: 31374909 PMCID: PMC6723989 DOI: 10.3390/nu11081775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/25/2022] Open
Abstract
Critically ill patients often require life support measures such as mechanical ventilation or haemodialysis. Despite the essential role of nutrition in patients’ recovery, the inappropriate use of medical nutrition therapy can have deleterious effects, as is the case with the use of respiratory, circulatory, or renal support. To increase awareness and to monitor the effects of inappropriate medical nutrition therapy, we propose to introduce the concept of nutritrauma in clinical practice, defined as metabolic adverse events related to the inappropriate administration of medical nutrition therapy or inadequate nutritional monitoring.
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Changing paradigms in metabolic support and nutrition therapy during critical illness. Curr Opin Crit Care 2019; 24:223-227. [PMID: 29901462 DOI: 10.1097/mcc.0000000000000519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW To summarize the most recent advances in acute metabolic care and critical care nutrition. RECENT FINDINGS Recent research has demonstrated unknown consequences of high protein and amino acid administration in the early phase of ICU stay associated with dysregulated glucagon release leading to hepatic amino acid breakdown and suggested adverse effects on autophagy and long-term outcome. Progress has been made to measure body composition in the ICU. Refeeding hypophosphatemia and refeeding syndrome are common during critical illness, phosphate monitoring is essential after the start of nutrition therapy, and caloric restriction is recommendable in these patients.In recent studies, enteral nutrition is no longer superior to parenteral nutrition and signals of harm using the enteral route in shock have been suggested. However, during extracorporeal life support, enteral nutrition seems well tolerated. Intermittent or bolus enteral feeding seems an exciting concept concerning its potential anabolic effects. Studies on vitamin C, thiamine, and corticosteroid combinations suggest potential to improve outcome. SUMMARY These new findings will probably change the practice of metabolic and nutrition therapy in critical illness and challenge paradigms advocated for long.
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