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Frederiks P, Peetermans M, Wilmer A. Nutritional support in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:373-379. [PMID: 38333990 DOI: 10.1093/ehjacc/zuae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/10/2024]
Abstract
Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.
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Affiliation(s)
- Pascal Frederiks
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
| | - Marijke Peetermans
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Alexander Wilmer
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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2
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Kamel AY. Measurement and estimation of energy in the critically ill. Curr Opin Crit Care 2024; 30:186-192. [PMID: 38441116 DOI: 10.1097/mcc.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Recent changes in guidelines recommendation during early phase of critical illness and use of indirect calorimetry. The aim of this review is to discuss methods of determining energy requirements in the critically ill and highlight factors impacting resting energy expenditure. RECENT FINDING An appraisal of recent literature discussing indirect calorimetry guided-nutrition potential benefits or pitfalls. Recent attempts to devise strategy and pilot indirect calorimetry use in the critically ill patients requiring continuous renal replacement therapy or extracorporeal membrane oxygenation are also discussed. Additionally, we briefly touched on variability between guidelines recommended energy target and measured energy expenditure for adult critically ill patients with obesity. SUMMARY While energy requirement in the critically ill continues to be an area of controversy, recent guidelines recommendations shift toward providing less aggressive calories during acute phase of illness in the first week of ICU.Use of indirect calorimetry may provide more accurate energy target compared to the use of predictive equations. Despite the absence of literature to support long term mortality benefits, there are many potential benefits for the use of indirect calorimetry when available.
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Affiliation(s)
- Amir Y Kamel
- Department of Pharmacy, UF Health Shands Hospital, University of Florida College of Pharmacy, Gainesville, Florida, USA
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3
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Zivick E, Kilgallon K, Cheifetz IM. Challenges of Nutrition Support in Pediatric Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:81-85. [PMID: 37788480 DOI: 10.1097/mat.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Nutrition support in critically ill infants and children remains an integral part of providing optimal care for these patients. The pediatric patient requiring extracorporeal membrane oxygenation therapy faces specific challenges to the provision of suitable nutrition support. In this review, we aimed to summarize the existing literature around some of the more challenging aspects of delivering appropriate nutrition to children receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Elizabeth Zivick
- From the Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Kevin Kilgallon
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine, Cleveland, Ohio
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4
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Dresen E, Modir R, Stoppe C. Nutrition support for patients on mechanical circulatory support. Curr Opin Anaesthesiol 2024; 37:24-34. [PMID: 37865830 DOI: 10.1097/aco.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW No specific guidelines on medical nutrition therapy (MNT) in patients on different types of mechanical circulatory support (MCS) devices yet exist and overall evidence is limited. The purpose of this narrative review is to provide an overview about current existing evidence, which might be of underrecognized importance for the patients' short-term and long-term clinical and functional outcomes. RECENT FINDINGS Patients on MCS inherit substantial metabolic, endocrinologic, inflammatory, and immunologic alterations, and together with the specificities of MCS therapy, technical modalities of respective devices, and concomitant medication, the consideration of individualized MNT approaches is indicated in routine clinical practice. Exemplarily, the evaluation of the patients' individual nutrition status, determination of nutrition targets, progressive increase of energy and protein supply throughout the different phases of disease, prevention of micronutrient deficiencies, implementation of nutrition protocols, appropriate monitoring strategies, and continuous quality improvement are essential elements of MNT in patients on MCS. SUMMARY The importance of MNT for patients on MCS still often remains underrecognized, which might be of particular relevance in view of the significant metabolic alterations, the long treatment period, and severity of illness in these patients. Further research on more targeted MNT approaches in those patients is urgently needed for the generation of evidence-based guidelines for this specific cohort of critically ill patients.
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Affiliation(s)
- Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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5
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Tatucu-Babet OA, Diehl A, Kratzing C, Lambell K, Burrell A, Tierney A, Nyulasi I, Bailey M, Sheldrake J, Ridley EJ. Modified indirect calorimetry for patients on venoarterial extracorporeal membrane oxygenation: a pilot feasibility study. Eur J Clin Nutr 2023; 77:888-894. [PMID: 37198437 PMCID: PMC10191396 DOI: 10.1038/s41430-023-01291-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND/OBJECTIVES Traditional indirect calorimetry is unable to capture complete gas exchange in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). We aimed to determine the feasibility of using a modified indirect calorimetry protocol in patients receiving VA ECMO, report measured energy expenditure (EE) and compare EE to control critically ill patients. SUBJECTS/METHODS Mechanically ventilated adult patients receiving VA ECMO were included. EE was measured within 72 h of VA ECMO commencement (timepoint one [T1]) and on approximately day seven of Intensive Care Unit (ICU) admission (timepoint two [T2]). Traditional indirect calorimetry via the ventilator was combined with calculations of oxygen consumption and carbon dioxide production derived from pre- and post-ECMO membrane blood gas analyses. Completion of ≥60% EE measurements was deemed feasible. Measured EE was compared between T1 and T2 and to control patients not receiving VA ECMO. Data is presented as n(%) and median[interquartile range (IQR)]. RESULTS Twenty-one patients were recruited; 16(76%) male, aged 55[42-64] years. The protocol was feasible to complete at T1 (14(67%)) but not at T2 (7(33%)) due to predominantly ECMO decannulation, extubation or death. EE was 1454[1213-1860] at T1 and 1657[1570-2074] kcal/d at T2 (P = 0.043). In patients receiving VA ECMO versus controls, EE was 1577[1434-1801] versus 2092[1609-2272] kcal/d, respectively (P = 0.056). CONCLUSION Modified indirect calorimetry is feasible early in admission to ICU but is not possible in all patients receiving VA ECMO, especially later in admission. EE increases during the first week of ICU admission but may be lower than EE in control critically ill patients.
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Affiliation(s)
- Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Nutrition Department, The Alfred, Melbourne, VIC, Australia.
| | - Arne Diehl
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | | | - Kate Lambell
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Audrey Tierney
- School of Allied Health and Health Implementation Science and Technology Centre, Health Research Institute, University of Limerick, Limerick, Ireland
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, VIC, Australia
| | - Ibolya Nyulasi
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
- Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, VIC, Australia
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Nutrition Department, The Alfred, Melbourne, VIC, Australia
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6
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Singer P, Statlender L. Beyond the limits of indirect calorimetry. Eur J Clin Nutr 2023; 77:925-926. [PMID: 37550537 DOI: 10.1038/s41430-023-01319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Pierre Singer
- Herzlia Medical Center intensive care unit and Reichman University, Herzlia, Israel.
| | - Liran Statlender
- Beilinson Medical Center, Institute for Nutrition Research, Petah Tiqwa, Israel
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Kim JY, Wie GA, Ryu KA, Kim SY. Nutrition Support in Critically Ill Cancer Patient Receiving Extracorporeal Membrane Oxygenation: A Case Report. Clin Nutr Res 2023; 12:91-98. [PMID: 37214778 PMCID: PMC10193437 DOI: 10.7762/cnr.2023.12.2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Adequate nutritional support is crucial in preventing complications and improving outcomes in critically ill patients. Extracorporeal membrane oxygenation (ECMO) is a mode of supportive care for patients with respiratory and/or cardiac failure. ECMO patients frequently exhibit a hypermetabolic state characterized by protein catabolism and insulin resistance, which can lead to malnutrition. Nutritional therapy is a vital component of intensive care, but its optimal administration for ECMO patients is unknown. This case report aims to provide insights into effective nutritional management for critically ill patients undergoing ECMO therapy. The patient was a 72-year-old male with a history of gastric and lung cancer who underwent a lobectomy complicated by bronchopleural fistula, postoperative bleeding, pneumonia, and acute respiratory distress syndrome (ARDS). The patient's nutritional status was assessed indicating a high risk of malnutrition, using the modified Nutrition Risk in the Critically Ill (mNUTRIC) Score. Nutritional support was administered based on the recommendations of European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), with energy requirements set at 25-30 kcal/kg/d and protein requirements set at 1.2-2.0 g/kg/day. The patient received parenteral nutrition until the enteral nutrition target amount was reached, with zinc supplements for wound healing. The study highlights the need for further research on proactive and effective nutritional support for ECMO patients to improve compliance and prognosis.
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Affiliation(s)
- Ji-Yeon Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Gyung-Ah Wie
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Kyoung-A Ryu
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - So-Young Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
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8
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Dresen E, Naidoo O, Hill A, Elke G, Lindner M, Jonckheer J, De Waele E, Meybohm P, Modir R, Patel JJ, Christopher KB, Stoppe C. Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice. JPEN J Parenter Enteral Nutr 2023; 47:220-235. [PMID: 36495215 DOI: 10.1002/jpen.2467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Omy Naidoo
- Newtricion Wellness Dieticians, PMB Healthcare Centre, Pietermaritzburg, South Africa
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joop Jonckheer
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Vrije Universiteit Brussel, Brussels Health Campus, Jette, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth B Christopher
- Renal Division, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
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9
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Measuring the Resting Energy Expenditure in Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:122-126. [PMID: 35471245 DOI: 10.1097/mat.0000000000001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Both overfeeding and underfeeding critically ill children are problematic. This prospective pilot study evaluated the resting energy expenditure in infants and children requiring extracorporeal membrane oxygenation (ECMO) support. An indirect calorimeter was used to measure oxygen consumption (VO 2 ) and carbon dioxide production (VCO 2 ) from the mechanical ventilator. Blood gases were used to determine VO 2 and VCO 2 from the ECMO circuit. Values from the mechanical ventilator and ECMO circuit were added, and the resting energy expenditure (REE) (Kcal/kg/day) was calculated. Measurements were obtained > 24 hours after ECMO support was initiated (day 2 of ECMO), 1 day before ECMO discontinuation or transfer, and 1 day after decannulation. Data were compared with the predicted energy expenditure. Seven patients aged 3 months to 13 years were included. The REE varied greatly both above and below predicted values, from 26 to 154 KCal/kg/day on day 2 of ECMO support. In patients with septic shock, the REE was > 300% above the predicted value on day 2 of ECMO. Before ECMO discontinuation, two of six (33%) children continued to have a REE > 110% of predicted. Three patients had measurements after decannulation, all with a REE < 90% of predicted. REE measurements can be obtained by indirect calorimetry in children receiving ECMO support. ECMO may not provide metabolic rest for all children as a wide variation in REE was observed. For optimal care, individual testing should be considered to match calories provided with the metabolic demand.
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Ong CS, Brown P, Shou BL, Wilcox C, Cho SM, Mendez-Tellez PA, Kim BS, Whitman GJR. Resting Energy Expenditure of Patients on Venovenous Extracorporeal Membrane Oxygenation for Adult Respiratory Distress Syndrome: A Pilot Study. Crit Care Explor 2022; 4:e0730. [PMID: 35923588 PMCID: PMC9296180 DOI: 10.1097/cce.0000000000000730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The objectives of this study were to 1) in patients without pulmonary function, determine resting energy expenditure (REE) in venovenous extracorporeal membrane oxygenation (ECMO) acute respiratory distress syndrome (ARDS) patients by paralysis status and 2) determine the threshold tidal volume (TV) associated with meaningful gas exchange as determined by measurable end-tidal carbon dioxide elimination (etV̇co2). DESIGN Retrospective observational study. SETTING A tertiary high ECMO volume academic institution. PATIENTS/SUBJECTS Ten adult ARDS patients on venovenous ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The modified Weir equation, Fick principle, Henderson-Hasselbalch equation, ECMO flow, hemoglobin, and pre and post oxygenator blood gases were used to determine ECMO carbon dioxide production (V̇co2), ECMO oxygen consumption, and REE. REE values were matched to patients' paralysis status based on medication flowsheets and compared using a paired t test. Linear regression was performed to determine the threshold TV normalized to ideal body weight (IBW) associated with measurable ventilator etV̇co2, above which meaningful ventilation occurs. When lungs were not functioning, patients had significantly lower mean REE when paralyzed (23.4 ± 2.8 kcal/kg/d) than when not paralyzed (29.2 ± 5.8 kcal/kg/d) (p = 0.02). Furthermore, mean REE was not similar between patients and varied as much as 1.7 times between patients when paralyzed and as much as 1.4 times when not paralyzed. Linear regression showed that ventilator V̇co2 was measurable and increased linearly when TV was greater than or equal to 0.7 mL/kg. CONCLUSIONS REE is patient-specific and varies significantly with and without patient paralysis. When TV exceeds 0.7 mL/kg IBW, ventilator V̇co2 increases measurably and must be considered in determining total REE.
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Affiliation(s)
- Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Patricia Brown
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher Wilcox
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | | | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Kapoor PM. Nutrition Aggrandizement while on ECMO. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1750425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesia and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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12
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Karpasiti T. A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:763-771. [PMID: 34324446 DOI: 10.1097/mat.0000000000001540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in patients with severe cardiorespiratory failure has seen significant growth in the last decade. Despite this, there is paucity of data surrounding the optimum nutritional management for ECMO patients. This review aimed to describe current nutrition practices in patients receiving ECMO, critically appraise available studies and identify areas for future research. A literature search was conducted in PubMed, MEDLINE, and CINAHL Plus to identify all randomized trials and observational studies published between July 2000 and July 2020 investigating nutrition practices in critically ill adults receiving ECMO. The primary outcomes were nutritional adequacy, gastrointestinal complications, and physical function. Secondary outcomes included mortality, length of stay, and duration on ECMO support. From a total of 31 studies identified, 12 met the inclusion criteria. Nine observational studies were reviewed following eligibility assessment. Early enteral nutrition was deemed safe and feasible for ECMO patients; however, meeting nutritional targets was challenging. Utilizing alternative nutrition routes is an option, although risks and benefits should be taken into consideration. Data on gastrointestinal complications and other clinical outcomes were inconsistent, and no data were identified investigating the effects of nutrition on the physical and functional recovery of ECMO patients. Nutrition therapy in ECMO patients should be provided in line with current guidelines for nutrition in critical illness until further data are available. Further prospective, randomized studies investigating optimum nutrition practices and effects on clinical and functional outcomes are urgently required.
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Affiliation(s)
- Terpsi Karpasiti
- From the Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
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13
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De Waele E, van Zanten ARH. Routine use of indirect calorimetry in critically ill patients: pros and cons. Crit Care 2022; 26:123. [PMID: 35513872 PMCID: PMC9069947 DOI: 10.1186/s13054-022-04000-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/25/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Elisabeth De Waele
- Department of Clinical Nutrition, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.,Intensive Care Unit, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine and Research, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands. .,Division of Human Nutrition and Health, Chair Group Nutritional Biology, Wageningen University and Research, HELIX (Building 124), Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
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14
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D'Alesio M, Martucci G, Arcadipane A, Lorusso R, Amrein K. Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines. Artif Organs 2022; 46:1240-1248. [PMID: 35230717 DOI: 10.1111/aor.14215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population. METHODS A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective. RESULTS Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day. CONCLUSIONS Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.
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Affiliation(s)
- Mark D'Alesio
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gennaro Martucci
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Antonio Arcadipane
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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15
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Honore PM, Redant S, Preseau T, Kaefer K, Barreto Gutierrez L, Anane S, Attou R, Gallerani A, De Bels D. Indirect calorimetry is the gold standard to assess REE in ICU patients: some limitations to consider. Crit Care 2021; 25:406. [PMID: 34823549 PMCID: PMC8613971 DOI: 10.1186/s13054-021-03817-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Patrick M Honore
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Sebastien Redant
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Thierry Preseau
- ED Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Keitiane Kaefer
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Leonel Barreto Gutierrez
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sami Anane
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Dept, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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16
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Hofheinz SB, Núñez-Ramos R, Germán-Díaz M, Melgares LO, Arroba CMA, López-Fernández E, Moreno-Villares JM. Which is the best route to achieve nutritional goals in pediatric ECMO patients? Nutrition 2021; 93:111497. [PMID: 34689035 DOI: 10.1016/j.nut.2021.111497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Estimating caloric intake and choosing route of administration are fundamental in the nutritional support of patients being supported by extracorporeal membrane oxygenation (ECMO). The aim of this study was to review the nutritional intervention carried out in a pediatric cohort in a third-level hospital. METHODS This was a prospective descriptive study. Age, sex, underlying pathology, Pediatric Risk of Mortality score, ECMO indication, type of care, duration of ECMO support, and prognosis were collected. Type of nutritional support, route of administration, kcal/kg achieved, estimated energy requirements, and percentage of caloric objective (%CO) reached on days 3 and 5 after cannulation were recorded. RESULTS Twenty-four venoarterial ECMO runs in 23 patients over a period of 2 y were recorded. Of the 23 patients, 15 were <1 y of age. The underlying pathology in 56.5% was cardiac disease. Three groups were identified: parenteral nutrition (group 0, n = 7), enteral nutrition (group 1, n = 8), and mixed nutrition (group 2, n = 7). The median of the %CO was 33.34 (0-84) on day 3 and 87.75% (78.4-100) on day 5 of ECMO, respectively for group 0; 75.5 (42.25-98.5) and 85% (24.4-107.7) in group 1 and 68.7 (44.4-82.2) and 91.2% (35.5-92) in group 2 (P > 0.05). Children <12 mo of age and cardiac patients represented 85.71% and 71.43% of total patients in group 0. Among the eight episodes of exclusive enteral nutrition, no complications were identified. CONCLUSION Enteral nutrition appears to be safe in the setting of hemodynamic stability and absence of contraindications and is equivalent to other nutritional interventions in terms of compliance with estimated energy requirements.
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Affiliation(s)
- Sylvia Belda Hofheinz
- Pediatric Intensive Care Department, University Hospital October 12, Madrid, Spain; School of Medicine, Department of Public and Maternal - Child Health, Complutense University of Madrid, Madrid, Spain
| | - Raquel Núñez-Ramos
- Pediatric Gastroenterology, Hepatology and Nutrition Unit. University Hospital October 12, Madrid, Spain.
| | - Marta Germán-Díaz
- Pediatric Gastroenterology, Hepatology and Nutrition Unit. University Hospital October 12, Madrid, Spain
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17
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Toh TSW, Ong C, Mok YH, Mallory P, Cheifetz IM, Lee JH. Nutrition in Pediatric Extracorporeal Membrane Oxygenation: A Narrative Review. Front Nutr 2021; 8:666464. [PMID: 34409059 PMCID: PMC8365758 DOI: 10.3389/fnut.2021.666464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) support is increasingly utilized in quaternary pediatric intensive care units. Metabolic derangements and altered nutritional requirements are common in critically ill children supported on ECMO. However, there remains no consensus on the optimal approach to the prescription of nutrition in these patients. This narrative review aims to summarize the current medical literature on various aspects of nutrition support in pediatric patients on ECMO. These include: (1) nutritional adequacy, (2) pros and cons of feeding on ECMO, (3) enteral vs. parenteral nutrition, and (4) proposed recommendations and future directions for research in this area.
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Affiliation(s)
- Theresa S W Toh
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ira M Cheifetz
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, United States
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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18
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De Waele E, Jonckheer J, Wischmeyer P. Indirect calorimetry in critical illness: a new standard of care? Curr Opin Crit Care 2021; 27:334-343. [PMID: 33990505 PMCID: PMC8367824 DOI: 10.1097/mcc.0000000000000844] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Review recent literature on the role of indirect calorimetry in critical care nutrition management. RECENT FINDINGS Critical illness demands objective, targeted nutritional therapy to prevent adverse effects of underfeeding/over feeding. Thus, all recent societal guidelines recommend indirect calorimetry use to determine energy needs. Very recently, indirect calorimetry technology has finally evolved to allow for accurate, simple, and routine utilization in a wider range of ICU patients. Recent data continues to confirm poor correlation between measured and equation-predicted energy expenditure emphasizing need for indirect calorimetry to be standard of care. This may be particularly true in COVID-19, where significant progressive hypermetabolism and variability in energy expenditure has been shown. Metabolic physiology can change frequently during ICU stay in response to changes in clinical condition or care. Thus, repeated longitudinal indirect calorimetry measures are needed throughout ICU stay to optimize care, with initial data showing improved clinical outcomes when indirect calorimetry targets are utilized. SUMMARY Personalized ICU care demands objective data to guide therapy. This includes use of indirect calorimetry to determine energy expenditure and guide ICU nutrition therapy. Long-awaited new innovations in indirect calorimetry technology should finally lead to indirect calorimetry to becoming a fundamental component of modern ICU standard of care and clinical research moving forward.
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Affiliation(s)
- Elisabeth De Waele
- Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussel, Belgium
- Department of Intensive Care Medicine, Universitair Ziekenhuis Brussel, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Joop Jonckheer
- Department of Intensive Care Medicine, Universitair Ziekenhuis Brussel, Belgium
| | - Paul Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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19
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von Renesse J, von Bonin S, Held HC, Schneider R, Seifert AM, Seifert L, Spieth P, Weitz J, Welsch T, Meisterfeld R. Energy requirements of long-term ventilated COVID-19 patients with resolved SARS-CoV-2 infection. Clin Nutr ESPEN 2021; 44:211-217. [PMID: 34330468 PMCID: PMC8238638 DOI: 10.1016/j.clnesp.2021.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 12/15/2022]
Abstract
Background & aims Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can rapidly progress into acute respiratory distress syndrome accompanied by multi-organ failure requiring invasive mechanical ventilation and critical care treatment. Nutritional therapy is a fundamental pillar in the management of hospitalized patients. It is broadly acknowledged that overfeeding and underfeeding of intensive care unit (ICU) patients are associated with increased morbidity and mortality. This study aimed to assess the energy demands of long-term ventilated COVID-19 patients using indirect calorimetry and to evaluate the applicability of established predictive equations to estimate their energy expenditure. Methods We performed a retrospective, single-center study in 26 mechanically ventilated COVID-19 patients with resolved SARS-CoV-2 infection in three independent intensive care units. Resting energy expenditure (REE) was evaluated by repetitive indirect calorimetry (IC) measurements. Simultaneously the performance of 12 predictive equations was examined. Patient's clinical data were retrieved from electronic medical charts. Bland-Altman plots were used to assess agreement between measured and calculated REE. Results Mean mREE was 1687 kcal/day and 20.0 kcal relative to actual body weight (ABW) per day (kcal/kg/day). Longitudinal mean mREE did not change significantly over time, although mREE values had a high dispersion (SD of mREE ±487). Obese individuals were found to have significantly increased mREE, but lower energy expenditure relative to their body mass. Calculated REE showed poor agreement with mREE ranging from 33 to 54%. Conclusion Resolution of SARS-CoV-2 infection confirmed by negative PCR leads to stabilization of energy demands at an average 20 kcal/kg in ventilated critically ill patients. Due to high variations in mREE and low agreement with calculated energy expenditure IC remains the gold standard for the guidance of nutritional therapy.
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Affiliation(s)
- Janusz von Renesse
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Simone von Bonin
- Department of Medicine I, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Hanns-Christoph Held
- University Centre of Surgery Intensive Care Unit, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Ralph Schneider
- Department of Medicine I, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Adrian M Seifert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Lena Seifert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany
| | - Ronny Meisterfeld
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany; University Centre of Surgery Intensive Care Unit, University Hospital Carl Gustav Carus, University of Technology Dresden, Dresden, Germany.
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20
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Wischmeyer PE, Molinger J, Haines K. Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit. Nutr Clin Pract 2021; 36:275-281. [PMID: 33734477 DOI: 10.1002/ncp.10643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeroen Molinger
- Department of Anesthesiology, Division of Critical Care, Human Pharmacology and Physiology Laboratory (HPPL), Duke University School of Medicine, Durham, North Carolina, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma Critical Care, and Acute Care Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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21
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Moonen HPFX, Beckers KJH, van Zanten ARH. Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations. J Intensive Care 2021; 9:8. [PMID: 33436084 PMCID: PMC7801790 DOI: 10.1186/s40560-021-00524-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/02/2021] [Indexed: 12/11/2022] Open
Abstract
The use of indirect calorimetry is strongly recommended to guide nutrition therapy in critically ill patients, preventing the detrimental effects of under- and overfeeding. However, the course of energy expenditure is complex, and clinical studies on indirect calorimetry during critical illness and convalescence are scarce. Energy expenditure is influenced by many individual and iatrogenic factors and different metabolic phases of critical illness and convalescence. In the first days, energy production from endogenous sources appears to be increased due to a catabolic state and is likely near-sufficient to meet energy requirements. Full nutrition support in this phase may lead to overfeeding as exogenous nutrition cannot abolish this endogenous energy production, and mitochondria are unable to process the excess substrate. However, energy expenditure is reported to increase hereafter and is still shown to be elevated 3 weeks after ICU admission, when endogenous energy production is reduced, and exogenous nutrition support is indispensable. Indirect calorimetry is the gold standard for bedside calculation of energy expenditure. However, the superiority of IC-guided nutritional therapy has not yet been unequivocally proven in clinical trials and many practical aspects and pitfalls should be taken into account when measuring energy expenditure in critically ill patients. Furthermore, the contribution of endogenously produced energy cannot be measured. Nevertheless, routine use of indirect calorimetry to aid personalized nutrition has strong potential to improve nutritional status and consequently, the long-term outcome of critically ill patients.
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Affiliation(s)
| | | | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, RP, Ede, The Netherlands.
- Division of Human Nutrition and Health, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708, WE, Wageningen, The Netherlands.
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22
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Al-Dorzi HM, Arabi YM. Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers. Nutr Clin Pract 2020; 36:88-97. [PMID: 33373481 DOI: 10.1002/ncp.10621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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23
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Davis RC, Durham LA, Kiraly L, Patel JJ. Safety, Tolerability, and Outcomes of Enteral Nutrition in Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2020; 36:98-104. [PMID: 33078433 DOI: 10.1002/ncp.10591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/31/2020] [Accepted: 09/20/2020] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a supportive care system for patients with respiratory or cardiac failure. Patients requiring ECMO are at risk for significant inflammation, prolonged hospitalization, and acquired malnutrition and sarcopenia. Societal guidelines recommend early enteral nutrition in critically ill patients; however, in this population, optimal timing and dose of nutrition remains unknown and fear of reduced splanchnic perfusion, delayed gastric emptying, and bowel ischemia poses a barrier to appropriate energy and protein intake. This narrative review intends to provide an overview of ECMO, highlight the rationale for nutrition support in this population, and review the safety, tolerability, and outcomes associated with enteral nutrition during ECMO.
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Affiliation(s)
- Robert C Davis
- Clinical Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laszlo Kiraly
- Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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24
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Using indirect calorimetry in place of fixed energy prescription was feasible and energy targets were more closely met: do not forget an important limitation. Crit Care 2020; 24:369. [PMID: 32560704 PMCID: PMC7304380 DOI: 10.1186/s13054-020-03075-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Leonel Barreto Gutierrez
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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25
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Yatabe T. Strategies for optimal calorie administration in critically ill patients. J Intensive Care 2019; 7:15. [PMID: 30915225 PMCID: PMC6416953 DOI: 10.1186/s40560-019-0371-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 03/01/2019] [Indexed: 12/14/2022] Open
Abstract
Nutritional therapy is one of the important treatments in critically ill patients. How to estimate calorie consumption and how to determine an optimal calorie dose are clinical questions of great importance. Although indirect calorimetry is the gold standard for assessing energy expenditure, many intensivists are unable to use this technique. Therefore, the use of formulas, such as the Harris-Benedict equation, or the simple predictive value of 25 kcal/kg/day is reasonable. Several studies and guidelines have shown that the strategies for nutritional therapy depend on the nutritional risk of patients. If patients have low nutritional risks, these estimated values should not be adopted in the acute phase. Until the patient’s condition improves, less than 18 kcal/kg/day might be an optimal calorie target. Contrastingly, cumulative negative energy balance can also be harmful to critically ill patients. Thus, it is important to accurately determine the energy requirement and to make the required changes in the administered calorie dose to go from a strategy of “defense” to that of “offense” in a timely manner. In this article, the concepts of optimal calorie administration in critically ill patients were reviewed.
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Affiliation(s)
- Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505 Japan
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