The nutritional and metabolic support of heart failure in the intensive care unit

Clinical and Nutritional Factors Associated With Early Mortality After Heart Transplantation

OBJECTIVE

The aim of this work was to verify the association between clinical and nutritional factors and mortality in the 1st 30 days after heart transplantation.

METHODS

This was a retrospective study of patients who underwent heart transplantation in a public hospital in Brazil from January 2013 to August 2015. The clinical and nutritional factors analyzed were: body mass index, body surface area, cachexia, infection, duration of orotracheal intubation, ejection fraction, mean pulmonary pressure, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score, hemoglobin, and diabetes mellitus. The primary outcome was mortality in the 1st 30 days after heart transplantation, and secondary outcomes were infection, acute kidney insufficiency, and duration of orotracheal intubation. We performed chi-square test, unpaired t test, and logistic regression in the analyses. A P value of < .05 was considered to be significant.

RESULTS

The sample had 103 patients, of which 16 patients (15.53%) died within 30 days after heart transplantation. We observed a relationship between death and orotracheal intubation duration (P < .01), postoperative creatinine (P < .01), acute kidney injury (P < .01), and INTERMACS score (P = .01) in the bivariate analysis but not in the multivariate model.

CONCLUSIONS

Clinical and nutritional factors had no impact on mortality up to 30 days after heart transplantation in this study, although orotracheal intubation duration, postoperative creatinine, acute kidney injury, and INTERMACS score were individually associated with early death.

Pediatric Heart Failure: A Practical Guide to Diagnosis and Management

Pediatric heart failure represents an important cause of morbidity and mortality in childhood. Currently, there are well-established guidelines for the management of heart failure in the adult population, but an equivalent consensus in children is lacking. In the clinical setting, ensuring an accurate diagnosis and defining etiology is essential to optimal treatment. Diuretics and angiotensin-converting enzyme inhibition are the first-line therapies, whereas beta-blockers and devices for electric therapy are less used in children than in adults. In the end-stage disease, heart transplantation is the best choice of treatment, while a left ventricular assist device can be used as a bridge to transplantation (due to the difficulties in finding organ donors), recovery (in the case of myocarditis), or destination therapy (for patients with systemic disease).

The role of micronutrients and macronutrients in patients hospitalized for heart failure

The detrimental pathophysiology of heart failure (HF) leaves room for physiologic and metabolomic concepts that include supplementation of micronutrients and macronutrients in these patients. Hence myocardial energetics and nutrient metabolism may represent relevant treatment targets in HF. This review focuses on the role of nutritive compounds such as lipids, amino acids, antioxidants, and other trace elements in the setting of HF. Supplementation of ferric carboxymaltose improves iron status, functional capacity, and quality of life in HF patients. To close the current gap in evidence further interventional studies investigating the role of micro- and macronutrients are needed in this setting.

[Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): cardiac patient]

Patients with cardiac disease can develop two types of malnutrition: cardiac cachexia, which appears in chronic congestive heart failure, and malnutrition due to the complications of cardiac surgery or any other type of surgery in patients with heart disease. Early enteral nutrition should be attempted if the oral route cannot be used. When cardiac function is severely compromised, enteral nutrition is feasible, but supplementation with parenteral nutrition is sometimes required. Sustained hyperglycemia in the first 24 hours in patients admitted for acute coronary syndrome, whether diabetic or not, is a poor prognostic factor for 30-day mortality. In critically-ill cardiac patients with stable hemodynamic failure, nutritional support of 20-25 kcal/kg/day is effective in maintaining adequate nutritional status. Protein intake should be 1.2*-1.5 g/kg/day. Routine polymeric or high protein formulae should be used, according to the patient's prior nutritional status, with sodium and volume restriction according to the patient's clinical situation. The major energy source for myocytes is glutamine, through conversion to glutamate, which also protects the myocardial cell from ischemia in critical situations. Administration of 1 g/ day of omega-3 (EPA+DHA) in the form of fish oil can prevent sudden death in the treatment of acute coronary syndrome and can also help to reduce hospital admission for cardiovascular events in patients with chronic heart failure.

Nutrition in heart failure: an update

PURPOSE OF REVIEW

Chronic heart failure (CHF) is increasingly recognized as a multisystem disease with important comorbidities such as anemia, insulin resistance, autonomic dysbalance, or cardiac cachexia.

RECENT FINDINGS

Apart from these perturbations, increasing evidence points to alterations in intestinal morphology, permeability, and absorption function in patients with CHF. This review provides an overview of the sonographic, histological, and functional abnormalities of different gastrointestinal regions. This intestinal dysfunction and disturbed intestinal barrier may lead to both the chronic inflammatory state and catabolic/anabolic imbalance as seen in cardiac cachexia, as a terminal stage of CHF, which carries a particularly poor prognosis. This review highlights the current knowledge of nutritional abnormalities that may occur in CHF, including fat, carbohydrates, proteins, water, and micronutrients. The regulation of feeding is discussed, as are nutritional strategies with potentially anti-inflammatory effects in the treatment of CHF.

SUMMARY

The gut and its role for inflammation and dietary interventions in heart failure patients are a crucial target of further heart failure research.

Recent insights on chronic heart failure, cachexia and nutrition

PURPOSE OF REVIEW

To provide recent observations on the interrelation between chronic heart failure (CHF), cachexia and human nutrition and updating epidemiological issues in CHF.

RECENT FINDINGS

Present evidence suggests that impairment in cardiac muscle energetics plays an important role in the pathogenesis of heart failure. New concepts such as microRNA expression are emerging as potential agents in heart failure. Recent research suggests mechanisms by which inflammatory catabolic states may persist in the presence of adequate growth factors and nutrition. A consensus panel has recently designed a definition for general cachexia and its stratification. Together with classicals, new nutrients and substrates are showing efficacies in the malnutrition associated with CHF. Although still promising, ghrelin, growth factors and other biological compounds maintain emergent therapeutical positions for heart failure or associated catabolic states or both.

SUMMARY

Altered intestinal function as an agent for CHF is rising in evidence. New techniques to well diagnose and stratify malnutrition and cardiac cachexia in CHF are needed. Treatment of cachexia in CHF appears to be a combination of different approaches, in which metabolic, nutritional, immunological and hormonal strategies may play an important role. Although the current experimental research is of great help, well designed randomized controlled trials are needed to test these hypothesis and generate clinical evidence.

Impact of new technologies on metabolic care in the intensive care unit

PURPOSE OF REVIEW

Technological innovations in the ICU have lead to extraordinary advances in modern critical care. Renal replacement therapy (RRT) innovations and ventricular assist devices (VAD) are now becoming common interventions in the ICU environment. The purpose of this article is to describe the impact of RRT and VAD on critical care medicine with particular reference to metabolic care.

RECENT FINDINGS

Continuous venovenous hemofiltration and slow low efficient daily dialysis are effective modalities of RRT in hemodynamically unstable patients. These continuous forms of RRT can result in accentuated protein and nutrient losses but also provide an opportunity for intradialytic parenteral nutrition support. VAD patients typically have cardiac cachexia and develop chronic critical illness syndrome. Intensive metabolic support, incorporating trophic, concentrated, semielemental enteral nutrition, supplemental parenteral nutrition, and intensive insulin therapy is a rational strategy to implement in VAD patients. Unfortunately, there is insufficient evidence at this time to support the routine use of these nutritional interventions with RRT and VAD.

SUMMARY

Patients requiring RRT or VAD are at high nutritional risk, which negatively affects ICU outcome. Prompt nutritional risk assessment and early optimization of metabolic care is crucial in this patient population.

Special commentary: a call for intensive metabolic support

PURPOSE OF REVIEW

This special commentary addresses recent clinical reviews regarding appropriate nutrition and metabolic support in the critical care setting.

RECENT FINDINGS

There are divergent approaches between North America and Europe for the use of early nutrition support and combined enteral nutrition and parenteral nutrition support possibly due to the commercial availability of specific parenteral nutrients. The advent of intensive insulin therapy has changed the landscape of metabolic support in the intensive care unit, and previous notions about infective risk of parenteral nutrition will need to be re-addressed. Patients with brain failure may benefit from an intensive insulin therapy with a blood glucose target that is higher than that used in patients without brain failure. Patients with heart failure may benefit from the addition of nutritional pharmacology that targets proximate oxidative pathophysiological pathways. Intradialytic parenteral nutrition may be viewed as another form of supplemental parenteral nutrition when enteral nutrition is insufficient in patients on hemodialysis in the intensive care unit.

SUMMARY

It is proposed that intensive metabolic support be routinely implemented in the intensive care unit based on the following steps: intensive insulin therapy with an appropriate blood glucose target, nutrition risk assessment, early and if needed combined enteral nutrition and parenteral nutrition to target 20-25 kcal/kg/day and 1.2-1.5 g protein/kg/day, and nutritional and metabolic monitoring.