Measuring nutrition-related outcomes in a cohort of multi-trauma patients following intensive care unit discharge

Ultrasound-derived rates of muscle wasting in the intensive care unit and in the post-intensive care ward for patients with critical illness: Post hoc analysis of an international, multicentre randomised controlled trial of early rehabilitation

BACKGROUND AND AIMS

Muscle wasting results in weakness for patients with critical illness. We aim to explore ultrasound-derived rates of change in skeletal muscle in the intensive care unit (ICU) and following discharge to the post-ICU ward.

DESIGN

Post hoc analysis of a multicentre randomised controlled trial of functional-electrical stimulated cycling, recumbent cycling, and usual care delivered in intensive care.

METHOD

Participants underwent ultrasound assessment of rectus femoris at ICU admission, weekly in the ICU, upon awakening, ICU discharge, and hospital discharge. The primary outcome was rate of change in rectus femoris cross-sectional area (ΔRFCSA) in mm2/day in the ICU (enrolment to ICU discharge) and in the post-ICU ward (ICU discharge to hospital discharge). Secondary outcomes included rate of change in echo intensity (ΔEI), standard deviation of echo intensity (ΔEISD), and the intervention effect on ultrasound measures. Echo intensity is a quantitative assessment of muscle quality. Elevated echo intensity may indicate fluid infiltration, adipose tissue, and reduced muscle quality.

RESULTS

154 participants were included (mean age: 58 ± 15 years, 34% female). Rectus femoris cross-sectional area declined in the ICU (-4 mm2/day [95% confidence interval {CI}: -9 to 1]) and declined further in the ward (-9 mm2/day [95% CI: -14 to -3]) with a mean difference between ICU and ward of -5 mm2/day ([95% CI: -2, to 11]; p = 0.1396). There was a nonsignificant difference in ΔEI between in-ICU and the post-ICU ward of 1.2 ([95% CI: -0.1 to 2.6]; p = 0.0755), a statistically significant difference in ΔEISD between in-ICU and in the post-ICU ward of 1.0 ([95% CI, 0.5 to 1.5]; p = 0.0003), and no difference in rate of change in rectus femoris cross-sectional area between groups in intensive care (p = 0.411) or at hospital discharge (p = 0.1309).

CONCLUSIONS

Muscle wasting occurs in critical illness throughout the hospital admission. The average rate of loss in muscle cross-sectional area does not slow after ICU discharge, even with active rehabilitation.

Evaluating physiological barriers to oral intake in hospitalized patients: A secondary analysis

BACKGROUND

Oral intake in hospitalized patients is frequently below estimated targets. Multiple physiological symptoms are proposed to impact oral intake, yet many have not been quantified objectively.

AIM

To describe the challenges of objectively measuring physiological nutrition-impacting symptoms in hospitalized patients.

METHOD

A secondary analysis of data from a single-center, descriptive cohort study of physiological nutrition-impacting symptoms in intensive care unit (ICU) survivors and general medical patients was conducted. Demographic and clinical characteristics were extracted for patients who completed the original study and collected retrospectively for those who were screened and recruited but did not complete the original study. Reasons for patient exclusion from the original study were quantified from the screening database. Descriptive data are reported as mean ± SD, median [interquartile range], or number (percentage).

RESULTS

ICU survivors and general medical patients were screened for inclusion in the original study between March 1 and December 23, 2021. Of the 644 patients screened, 97% did not complete the study, with 93% excluded at screening. Of the 266 ICU survivors and 398 general medical patients screened, 89% and 95% were excluded, respectively. Major exclusion criteria included the inability to follow commands or give informed consent (n = 155, 25%), the inability to consume the easy-to-chew and thin-fluid buffet meal, and imminent discharge (both, n = 120, 19%).

CONCLUSION

Understanding physiological factors that drive reduced oral intake in hospitalized patients is challenging. Exclusion criteria required to objectively quantify physiological nutrition-impacting symptoms significantly preclude participation and likely act as independent barriers to oral intake.

Nutritional gap after transfer from the intensive care unit to a general ward - A retrospective quality assurance study

BACKGROUND

Adequate nutrition is important for recovery after critical illness. Even so, our knowledge of patients' nutritional intake after intensive care unit (ICU) discharge is scarce.

OBJECTIVES

We aimed to explore nutritional planning and achieved nutritional intake in ICU patients who transfer from the ICU to general wards.

METHODS

A retrospective quality assurance study.

INCLUSION CRITERIA

adult ICU patients transferring to a general ward at Copenhagen University Hospital-Herlev from May to August 2021. Primary outcomes were as follows: having a nutritional plan on the day of ICU transfer. A nutritional plan was defined as follows: (i) individual assessment of energy and protein requirement; (ii) intake, documented as achieved percentage of energy and protein requirements; (iii) prescribed type of nutrition. If using enteral or parenteral nutrition; (iv) the prescribed doses; and (v) the prescribed product. Secondary outcomes were as follows: achieved percentage of energy and protein requirements from day -1 before ICU transfer until day +1 and day +3 after ICU transfer.

RESULTS

We included 57 patients; the mean age was 64 years (±11.1); 43 (75%) patients were male; the median ICU stay was 6 days (interquartile range: 3-11). One (2%) patient had a full nutritional plan according to listed criteria. Patients' median percentage of requirements met declined significantly from the day before to the day after ICU discharge (energy: from 94% to 30.5%; p = 0.0051; protein: from 73% to 27.5%; p = 0.0117). The decline in percentage of requirements met remained unchanged from day 1 to 3 after ICU transfer.

CONCLUSIONS

In conclusion, few patients had a nutritional plan when transferring from the ICU to a general ward. After ICU discharge, percentage of energy and protein requirements met declined significantly and remained insufficient during the first 3 days at the general ward.

A Randomized Noninferiority Trial to Compare Enteral to Parenteral Phosphate Replacement on Biochemistry, Waste, and Environmental Impact and Healthcare Cost in Critically Ill Patients With Mild to Moderate Hypophosphatemia

OBJECTIVES

Hypophosphatemia occurs frequently. Enteral, rather than IV, phosphate replacement may reduce fluid replacement, cost, and waste.

DESIGN

Prospective, randomized, parallel group, noninferiority clinical trial.

SETTING

Single center, 42-bed state trauma, medical and surgical ICUs, from April 20, 2022, to July 1, 2022.

PATIENTS

Patients with serum phosphate concentration between 0.3 and 0.75 mmol/L.

INTERVENTIONS

We randomized patients to either enteral or IV phosphate replacement using electronic medical record-embedded program.

MEASUREMENT AND MAIN RESULTS

Our primary outcome was serum phosphate at 24 hours with a noninferiority margin of 0.2 mmol/L. Secondary outcomes included cost savings and environmental waste reduction and additional IV fluid administered. The modified intention-to-treat cohort comprised 131 patients. Baseline phosphate concentrations were similar between the two groups. At 24 hours, mean ( sd ) serum phosphate concentration were enteral 0.89 mmol/L (0.24 mmol/L) and IV 0.82 mmol/L (0.28 mmol/L). This difference was noninferior at the margin of 0.2 mmol/L (difference, 0.07 mmol/L; 95% CI, -0.02 to 0.17 mmol/L). When assigned IV replacement, patients received 408 mL (372 mL) of solvent IV fluid. Compared with IV replacement, the mean cost per patient was ten-fold less with enteral replacement ($3.7 [$4.0] vs. IV: $37.7 [$31.4]; difference = $34.0 [95% CI, $26.3-$41.7]) and weight of waste was less (7.7 g [8.3 g] vs. 217 g [169 g]; difference = 209 g [95% CI, 168-250 g]). C O2 emissions were 60-fold less for comparable phosphate replacement (enteral: 2 g producing 14.2 g and 20 mmol of potassium dihydrogen phosphate producing 843 g of C O2 equivalents).

CONCLUSIONS

Enteral phosphate replacement in ICU is noninferior to IV replacement at a margin of 0.2 mmol/L but leads to a substantial reduction in cost and waste.

Observed differences in nutrition management at two time points spanning a decade in critically ill trauma patients with and without head injury

BACKGROUND

Nutritional needs of trauma patients admitted to the intensive care unit may differ from general critically ill patients, but most current evidence is based on large clinical trials recruiting mixed populations.

OBJECTIVE

The aim of the study was to investigate nutrition practices at two time points that span a decade in trauma patients with and without head injury.

METHODS

This observational study recruited adult trauma patients receiving mechanical ventilation and artificial nutrition from a single-centre intensive care unit between February 2005 to December 2006 (cohort 1), and December 2018 to September 2020 (cohort 2). Patients were categorised into head injury and non-head injury subgroups. Data regarding energy and protein prescription and delivery were collected. Data are presented as median [interquartile range]. Wilcoxon rank-sum test assessed the differences between cohorts and subgroups, with a P value ≤ 0.05. The protocol was registered with the Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001816246).

RESULTS

Cohort 1 included 109 patients, and 112 patients were included in cohort 2 (age: 46 ± 19 vs 50 ± 19 y; 80 vs 79% M). Overall, nutrition practice did not differ between head-injured and non-head-injured subgroups (all P > 0.05). Energy prescription and delivery decreased from time point one to time point two, regardless of subgroup (Prescription: 9824 [8820-10 581] vs 8318 [7694-9071] kJ; Delivery: 6138 [5130-7188] vs 4715 [3059-5996] kJ; all P < 0.05). Protein prescription did not change from time point one to time point two. Although protein delivery remained constant from time point one to time point two in the head injury group, protein delivery reduced in the non-head injury subgroup (70 [56-82] vs 45 [26-64] g/d, P < 0.05).

CONCLUSION

In this single-centre study, energy prescription and delivery in critically ill trauma patients reduced from time point one to time point two. Protein prescription did not change, but protein delivery reduced from time point one to time point two in non-head injury patients. Reasons for these differing trajectories require exploration.

STUDY REGISTRATION

Trial registered at www.anzctr.org.au.

TRIAL ID

ACTRN12618001816246.

Post-intensive care syndrome follow-up system after hospital discharge: a narrative review

BACKGROUND

Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.

MAIN TEXT

The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.

CONCLUSIONS

This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.

Beta-hydroxy-beta-methylbutyrate supplementation and functional outcomes in multitrauma patients: A pilot randomized controlled trial

BACKGROUND

Beta-hydroxy-beta-methylbutyrate (HMB) is a nutrition supplement that may attenuate muscle wasting from critical illness. This trial aimed to determine feasibility of administering a blinded nutrition supplement in the intensive care unit (ICU) and continuing it after ICU discharge.

METHODS

Single-center, parallel-group, blinded, placebo-controlled, randomized feasibility trial. After traumatic injury necessitating admission to ICU, participants were randomized to receive an enteral study supplement of 3 g of HMB (intervention) or placebo daily for 28 days or until hospital discharge. Primary outcome was feasibility of administering the study supplement, quantified as protocol adherence. Secondary outcomes included change in quadriceps muscle thickness, measured weekly until day 28 or hospital discharge by using ultrasound and analyzed by using a linear mixed model.

RESULTS

Fifty randomized participants (intervention, n = 26; placebo, n = 24) showed comparable baseline characteristics. Participants received 862 (84.3%) of the 1022 prescribed supplements during hospitalization with 543 (62.8%) delivered via an enteral feeding tube. The median (IQR) number of study supplements successfully administered per participant was 19.5 (13.0-24.0) in the intervention group and 16.5 (8.5-23.5) in the placebo group. Marked loss of quadriceps muscle thickness occurred in both groups, with the point estimate favoring attenuated muscle loss with the intervention, albeit with wide CIs (mean intervention difference after 28 days, 0.26 cm [95% CI, -0.13 to 0.64]).

CONCLUSION

A blinded, placebo-controlled, randomized clinical trial of daily enteral HMB supplementation for up to 28 days in hospital is feasible. Any effect of HMB supplementation to attenuate muscle wasting after traumatic injury remains uncertain.

Nutrition care processes across hospitalisation in critically ill patients with COVID-19 in Australia: A multicentre prospective observational study

BACKGROUND

The COVID-19 pandemic highlighted major challenges with usual nutrition care processes, leading to reports of malnutrition and nutrition-related issues in these patients.

OBJECTIVE

The objective of this study was to describe nutrition-related service delivery practices across hospitalisation in critically ill patients with COVID-19 admitted to Australian intensive care units (ICUs) in the initial pandemic phase.

METHODS

This was a multicentre (nine site) observational study in Australia, linked with a national registry of critically ill patients with COVID-19. Adult patients with COVID-19 who were discharged to an acute ward following ICU admission were included over a 12-month period. Data are presented as n (%), median (interquartile range [IQR]), and odds ratio (OR [95% confidence interval {CI}]).

RESULTS

A total of 103 patients were included. Oral nutrition was the most common mode of nutrition (93 [93%]). In the ICU, there were 53 (52%) patients seen by a dietitian (median 4 [2-8] occasions) and malnutrition screening occurred in 51 (50%) patients most commonly with the malnutrition screening tool (50 [98%]). The odds of receiving a higher malnutrition screening tool score increased by 36% for every screening in the ICU (1st to 4th, OR: 1.39 [95% CI: 1.05-1.77] p = 0.018) (indicating increasing risk of malnutrition). On the ward, 51 (50.5%) patients were seen by a dietitian (median time to consult: 44 [22.5-75] hours post ICU discharge). The odds of dietetic consult increased by 39% every week while on the ward (OR: 1.39 [1.03-1.89], p = 0.034). Patients who received mechanical ventilation (MV) were more likely to receive dietetic input than those who never received MV.

CONCLUSIONS

During the initial phases of the COVID-19 pandemic in Australia, approximately half of the patients included were seen by a dietitian. An increased number of malnutrition screens were associated with a higher risk score in the ICU and likelihood of dietetic consult increased if patients received MV and as length of ward stay increased.

Nutrition care processes from intensive care unit admission to inpatient rehabilitation: A retrospective observational study

OBJECTIVES

Extended duration of nutrition interventions in critical illness is a plausible mechanism of benefit and of interest to inform future research. The aim of this study was to describe nutrition processes of care from intensive care unit (ICU) admission to discharge from inpatient rehabilitation.

METHODS

This was a single-center retrospective study conducted at a health care network in Melbourne, Australia. Adult patients in the ICU >48 h and discharged to inpatient rehabilitation within 28 d were included. Dietitian assessment data and nutrition impacting symptoms were collected until day 28. Data are presented as n (%), mean ± SD or median (interquartile range).

RESULTS

Fifty patients were included. Of the 50 patients, 28 were men (56%). Patients were 65 ± 19 y of age with an Acute Physiology And Chronic Health Evaluation II score 15.5 ± 5.2. ICU length of stay (LOS) was 3 d (3-6), acute ward LOS was 10 d (7-14), and rehabilitation LOS was 17 d (8-37). Patients assessed by a dietitian and days to assessment in ICU, acute ward, and rehabilitation were 43 (86%) and 1 (0-1); 42 (84%) and 1 (1-3), and 32 (64%) and 2 (1-4) d, respectively. Oral nutrition was the most common mode: 40 (80%) in the ICU and 48 (96%) on the acute ward and rehabilitation. There was at least one nutrition impacting symptom reported in 44 patients (88%).

CONCLUSIONS

Rehabilitation LOS was longer than in the ICU or acute wards, yet patients in rehabilitation were assessed the least by a dietitian and time to assessment was longest. Symptoms that impact nutrition intake were common; nutrition interventions beyond the acute care setting in critical illness need investigation.

Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness

BACKGROUND

Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients.

METHODS

Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group.

RESULTS

Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25).

CONCLUSIONS

Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.

Nutritional issues concerning general medical ward patients: feeding patients recovering from critical illness

PURPOSE OF REVIEW

ICU survivors often spend long periods of time in general wards following transfer from ICU in which they are still nutritionally compromised. This brief review will focus on the feeding of patients recovering from critical illness, as no formal recommendations or guidelines on nutrition management are available for this specific situation.

RECENT FINDINGS

While feeding should start in the ICU, it is important to continue and adapt nutritional plans on the ward to support individuals recovering from critical illness. This process is highly complex - suboptimal feeding may contribute significantly to higher morbidity and mortality, and seriously hinder recovery from illness. Recently, consensus diagnostic criteria for malnutrition have been defined and large-scale trials have advanced our understanding of the pathophysiological pathways underlying malnutrition. They have also helped further develop treatment algorithms. However, we must continue to identify specific clinical parameters and blood biomarkers to further personalize therapy for malnourished patients. Better understanding of such factors may help us adapt nutritional plans more efficiently.

SUMMARY

Adequate nutrition is a vigorous component of treatment in the post-ICU period and can enhance recovery and improve clinical outcome. To better personalize nutritional treatment because not every patient benefits from support in the same manner, it is important to further investigate biomarkers with a possible prognostic value.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Poor physical recovery after critical illness: incidence, features, risk factors, pathophysiology, and evidence-based therapies

PURPOSE OF REVIEW

To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness.

RECENT FINDINGS

New physical problems after ICU survival, such as muscle weakness, weakened condition, and reduced exercise capacity, are the most frequently encountered limitations of patients with postintensive care syndrome. Disabilities may persist for months to years and frequently do not fully recover. Hormonal and mitochondrial disturbances, impaired muscle regeneration due to injured satellite cells and epigenetic differences may be involved in sustained ICU-AW. Although demographics and ICU treatment factors appear essential determinants for physical recovery, pre-ICU health status is also crucial. Currently, no effective treatments are available. Early mobilization in the ICU may improve physical outcomes at ICU-discharge, but there is no evidence for benefit on long-term physical recovery.

SUMMARY

Impaired physical recovery is observed frequently among ICU survivors. The pre-ICU health status, demographic, and ICU treatment factors appear to be important determinants for physical convalescence during the post-ICU phase. The pathophysiological mechanisms involved are poorly understood, thereby resulting in exiguous evidence-based treatment strategies to date.

β-Hydroxy-β-methylbutyrate (HMB) supplementation and functional outcomes in multi-trauma patients: a study protocol for a pilot randomised clinical trial (BOOST trial)

Background

There are no therapies proven to diminish the muscle wasting that occurs in patients after major trauma who are admitted to the intensive care unit (ICU). β-Hydroxy-β-methylbutyrate (HMB) is a nutrition intervention that may attenuate muscle loss and, thereby, improve recovery. The primary aim of this study is to determine the feasibility of a blinded randomised clinical trial of HMB supplementation to patients after major trauma who are admitted to the ICU. Secondary aims are to establish estimates for the impact of HMB when compared to placebo on muscle mass and nutrition-related patient outcomes.

Methods

This prospective, single-centre, blinded, randomised, placebo-controlled, parallel-group, feasibility trial with allocation concealment will recruit 50 participants over 18 months. After informed consent, participants will be randomised [1:1] to receive either the intervention (three grams of HMB dissolved in either 150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed) or placebo (150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed). The intervention will be commenced in ICU, continued after ICU discharge and ceased at hospital discharge or day 28 post randomisation, whichever occurs first. The primary outcome is the feasibility of administering the intervention. Secondary outcomes include change in muscle thickness using ultrasound and other nutritional and patient-centred outcomes.

Discussion

This study aims to determine the feasibility of administering HMB to critically ill multi-trauma patients throughout ICU admission until hospital discharge. Results will inform design of a larger randomised clinical trial.

Trial registration

The protocol is registered with Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTR: 12620001305910. UTN: U1111-1259-5534.

Medical nutrition therapy for patients with malnutrition post-intensive care unit discharge: A case report of recovery from coronavirus disease 2019 (COVID-19)

Patients discharged from an intensive care unit (ICU) are frequently malnourished and experience ongoing inadequate nutrition intake because of a variety of barriers, which may lead to further declines in nutrition status. The coronavirus disease 2019 (COVID-19) pandemic has drawn increased awareness to this vulnerable patient population and the importance of nutrition rehabilitation to promote optimal recovery from acute illness. Despite this, there are no formal guidelines addressing medical nutrition therapy during the post-ICU recovery phase. This review provides an overview of the nutrition management of patients during the post-ICU recovery phase with a specific focus on COVID-19. A case study will demonstrate how medical nutrition therapy improved the nutrition status and quality of life for a patient who became severely malnourished after a prolonged hospitalization for COVID-19.

Prioritizing nutrition during recovery from critical illness

PURPOSE OF REVIEW

Patients admitted to the intensive care unit (ICU) often experience a significant decline in nutritional status due to a combination of the physiologic response to critical illness and insufficient calorie intake. The majority of research related to nutrition interventions for this population focuses on nutrition support during the acute phase. Minimal attention is given to the nutritional status of ICU patients during the recovery phase. This review will describe calorie intake when ICU care ends, provide an overview of barriers that limit intake, and possible interventions to improve nutritional status.

RECENT FINDINGS

Current evidence suggests patients are consuming < 60% of calorie requirements after extubation and ICU discharge. This inadequate calorie intake may exacerbate weight loss and muscle and fat wasting. Physiologic, physical, and cognitive manifestations of critical illness can lead to multiple issues that cause poor intake. Possible interventions to improve calorie intake include a patient-centered approach that utilizes oral nutrition supplements and enteral nutrition.

SUMMARY

Consuming adequate caloric intake in the recovery phase of critical illness is essential for rehabilitation. A systematic, patient centered approach that includes close monitoring of calorie and protein and timely interventions may be the best method to improve overall intake.

Assessment of muscle mass using ultrasound with minimal versus maximal pressure compared with computed tomography in critically ill adult patients

BACKGROUND

Preserved skeletal muscle mass identified using computed tomography (CT) predicts improved outcomes from critical illness; however, CT imaging have few limitations such that it involves a radiation dose and transferring patients out of the intensive care unit. This study aimed to assess in critically ill patients the relationship between muscle mass estimates obtained using minimally invasive ultrasound techniques with both minimal and maximal pressure compared with CT images at the third lumber vertebra level.

METHODS

All patients were treated in a single Australian intensive care unit. Eligible patients had paired assessments, within a 72-h window, of muscle mass by ultrasound (quadriceps muscle layer thickness in centimetres, with maximal and minimal pressure) and CT axial cross-sectional area (cm²). Data are presented as mean (standard deviation), median (interquartile range), and frequencies [n (%)].

RESULTS

Thirty-five patients [mean (standard deviation) age = 55 (16) years, median (interquartile range) body mass index = 27 (25-32) kg/m², and 26 (74%) men] contributed 41 paired measurements. Quadriceps muscle thickness measured using the maximal pressure technique was a strong independent predictor of lumbar muscle cross-sectional area. Within a multivariate mixed linear regression model and adjusting for sex, age, and body mass index, for every 1 cm increase in quadriceps muscle layer thickness, the lumbar muscle cross-sectional area increased by 35 cm² (95% confidence interval = 11-59 cm²). Similar univariate associations were observed using minimal pressure; however, as per multivariate analysis, there was no strength in this relationship [8 cm² (95% confidence interval = -5 to 22 cm²)].

CONCLUSION

Ultrasound assessment of the quadriceps muscle using maximal pressure reasonably predicts the skeletal muscle at the third lumbar vertebra level of critically ill patients. However, there is substantial uncertainty within these regression estimates, and this may reduce the current utility of this technique as a minimally invasive surrogate for CT assessment of skeletal muscle mass.

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosole exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.