How soon should we start interventional feeding in the ICU?

Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Percutaneous trans-stomal jejunostomy: a new technique

AIM

We propose a new technique for feeding a malnourished patient with a "high" double-barrel jejunostomy (at about 60 cm from the Treitz Ligament). The procedure aims to restore an adequate nutritional state maintaining a correct diet for 24 h a day, without complications and without interfering with the normal activity of the nurses caring for the stoma.

METHOD

Using local anesthesia, we introduced a Reverdin needle through the efferent loop of jejunostomy and externalized it through the skin, medially from jejunostomy of about 10 cm. Using this guide, we inserted an enteral feeding tube with a blunt tip and then introduced it through the efferent loop to reach about 40 cm distantly into the bowel.

RESULTS

The stoma output decreased from 3 to 1.5 L/day; kidney status was restored to normal function.

CONCLUSION

The main advantages are the minimal invasiveness of the implantation procedure, the possibility of nutrition during all 24 h, and the easy management by nurses.

Perspectives: on Precision Nutrition Research in Heart, Lung, and Blood Diseases and Sleep Disorders

The release of the 2020-2030 Strategic Plan for NIH Nutrition Research (SPNR) and its emphasis on precision nutrition has provided an opportunity to identify future nutrition research that addresses individual variability in response to diet and nutrition across the life span-including those relevant to the Strategic Vision of the National Heart, Lung, and Blood Institute (NHLBI). The SPNR and the NHLBI's Strategic Vision were developed with extensive input from the extramural research community, and both have 4 overarching strategic goals within which are embedded several objectives for research. For the SPNR, these include 1) spur discovery science and normal biological functions (e.g., role of the microbiome in health and disease), 2) population science to understand individual differences (e.g., biomarkers including 'omics that predict disease status), 3) emerging scientific areas of investigation and their application (e.g., data science, artificial intelligence), and 4) cross-cutting themes (e.g., training the scientific workforce and minority health and health disparities). These strategic goals and objectives serve as blueprints for research and training. Nutrition remains important in the prevention and treatment of heart, lung, blood, and sleep (HLBS) disorders and diseases, and the NHLBI has played a pivotal role in supporting nutrition research. In this paper, we report important gaps in the scientific literature related to precision nutrition in HLBS diseases. Research opportunities that could stimulate precision nutrition and their alignment with the SPNR and the NHLBI Strategic Vision Objectives are provided. These opportunities include 1) exploring individual differences in response to varying dietary patterns and nutrients; 2) investigating genetic/epigenetic, biological (e.g., microbiome, biomarkers), social, psychosocial, and environmental underpinnings of individual variability in diet; 3) elucidating the role of circadian rhythm and chrononutrition; and 4) applying implementation science research methods in precision nutrition interventions relevant to HLBS diseases.

A data-driven model of the role of energy in sepsis

Exposure to pathogens elicits a complex immune response involving multiple interdependent pathways. This response may mitigate detrimental effects and restore health but, if imbalanced, can lead to negative outcomes including sepsis. This complexity and need for balance pose a challenge for clinicians and have attracted attention from modelers seeking to apply computational tools to guide therapeutic approaches. In this work, we address a shortcoming of such past efforts by incorporating the dynamics of energy production and consumption into a computational model of the acute immune response. With this addition, we performed fits of model dynamics to data obtained from non-human primates exposed to Escherichia coli. Our analysis identifies parameters that may be crucial in determining survival outcomes and also highlights energy-related factors that modulate the immune response across baseline and altered glucose conditions.

Comparison of Different Early Enteral Feeding Formulas on Critically Ill Patients

Critically ill patients are physiologically unstable, often have complex hypermetabolic responses to trauma. These patients are facing a high risk of death, multi-organ failure, and prolonged ventilator use. Nutrition is one of therapy for critical illness, however, patients often experience malnutrition caused by disease severity, delays in feeding, and miscalculation of calorie needs. The study aims to evaluate clinical improvement in critically ill participants that were given 3 kinds of early enteral feeding formulas, which were control (5% Dextrose), high-protein polymeric, or oligomeric formulas. A total of 55 critically ill participants admitted to the intensive care unit (ICU) between October 2017-March 2018 and assigned in this controlled trial. Early enteral feeding was initiated within 24-48 h after ICU admission. Each enteral feeding group were categorized to traumatic brain injury (TBI) or non-TBI. The primary endpoints were changes in white blood cell count, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Nutrition Risk in the Critically Ill (NUTRIC) score from baseline to day 3. Baseline characteristics were similar between control (n=22), high-protein polymeric (n=19) and oligomeric (n=14) groups. There were significant decreases for white blood cell count (13,262.5±6,963.51 to 11,687.5±7,420.92; p=0.041), APACHE II score (17.33±3.31 to 13.83±1.95; p=0.007), and NUTRIC scores changes (3.08±1.44 to 1.92±1.00; p=0.022) in non-TBI participants receiving highprotein polymeric compared those in control or oligomeric participants. But there is no significant clinical improvement in TBI patients. In conclusion, non-TBI patients benefit from early enteral feeding with high-protein polymeric formula.

Effect of Tubular Feeding with the Measurement of Gastric Residual Volume on Ventilator Associated Pneumonia

Background

Several measures have been taken to prevent the onset of ventilator-associated pneumonia (VAP), one of which is measuring the gastric residual volume. The purpose of this study is to compare the effect of two tube feeding methods with and without gastric residual volume measurement on VAP.

Materials and Methods

This clinical trial was performed on the study population of patients with endotracheal tubes hospitalized in Intensive Care Units 1 and 2 of Golestan hospital, Ahvaz, Iran. Overall, 70 patients who met the inclusion criteria were randomly divided into groups 1 and 2. Groups 1 and 2 were fed with and without measuring gastric residual volume, respectively. The incidence of pneumonia was assessed using the Modified Clinical Pulmonary Infection Score prior to the intervention and on the fifth day post- intervention. The data were analyzed by the SPSS software version 22.

Results

The incidence of VAP was 9.12% in the group with gastric residual volume measurement and 7.14% in the other group. There was no significant difference between the two groups (P=0.827) regarding VAP prevalence.

Conclusion

Monitoring gastric residual v olume requires aspiration and repeated measurements of gastric contents, resulting in increased nursing workload. Moreover, if the gastric residual volume is high, the patient will be deprived of calorie intake and subjected to malnutrition. As a result, removing the monitoring of gastric residual volume from the care setting and focusing on interventions proven to reduce VAP can be more helpful.

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care on the Duration of Mechanical Ventilator for Critically Ill Patients

PURPOSE

Early enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical outcomes.

METHODS

This study compares a pretest-posttest design for the two groups, which was done before and after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit (ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG started within the first 48 hours of admission to the ICU, and for the control group, they received standard nursing care.

RESULTS

After the implementation, it showed significant associations between the duration of mechanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter starting time of EN and a reduced duration of mechanical ventilator than those in the control group (p < .001).

CONCLUSION

A CNPG for EN care reduced the duration of mechanical ventilator. This could possibly improve the delivery of target calories when compared with current standard practice and improve the outcome of critically ill patients.

Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.

Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials

The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.