Observational study evaluating the nutritional impact of changing from 1% to 2% propofol in a cardiothoracic adult critical care unit

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines

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.

Nutritional Support Protocol for patients with COVID-19

Background & aims

COVID-19 is a hypercatabolic disease with possible pulmonary and gastrointestinal symptoms, and consequent deterioration of the nutritional status and the worst clinical prognosis. This study presents a protocol to guide the nutritional care of adult and elderly people non-critically and critically ill with COVID-19.

Methods

A critical review of the literature was carried out in the databases PubMed, Scielo, Bireme, and Science Direct, in search of articles and guidelines that presented assessment criteria and nutritional conduct for COVID-19 and Severe Acute Respiratory Syndrome (SARS), as well as guidelines for managing the symptoms presented by patients.

Results

The results are recommendations based on the literature and the professional experience of nutritionists who provide nutritional assistance to individuals hospitalized with COVID-19 since the beginning of the pandemic in Brazil. We present tools and suggestions for assessing the nutritional status, calculating nutritional needs, initiating nutritional therapy and monitoring tolerance to it, nutritional monitoring during hospitalization, and guidelines for hospital discharge.

Conclusion

Patients with COVID-19 are at nutritional risk. A complete nutritional assessment (anthropometric, dietary, and laboratory assessment) enables the establishment of an individualized nutritional approach in order to contribute to better clinical and nutritional prognoses.

Methodological Aspects of Indirect Calorimetry in Patients with Sepsis-Possibilities and Limitations

The aim of the review was to analyse the challenges of using indirect calorimetry in patients with sepsis, including the limitations of this method. A systematic review of the literature was carried out. The analysis concerned the methodology and presentation of research results. In most studies assessing energy expenditure, energy expenditure was expressed in kcal per day (n = 9) and as the mean and standard deviation (n = 7). Most authors provided a detailed measurement protocol, including measurement duration (n = 10) and device calibration information (n = 7). Ten papers provided information on the day of hospitalisation when the measurements were obtained, nine on patient nutrition, and twelve on the criteria for inclusion and exclusion of participants from the study. Small study group sizes and study at a single centre were among the most cited limitations. Studies assessing energy expenditure in patients with sepsis by indirect calorimetry differ in the methodology and presentation of results, and their collective analysis is difficult. A meta-analysis of the results could enable multi-site and large patient evaluation. Standardisation of protocols and presentation of all collected data would enable their meta-analysis, which would help to achieve greater knowledge about metabolism in sepsis.

Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support

Propofol, a commonly used sedative in the intensive care unit, is formulated in a 10% lipid emulsion that contributes 1.1 kcals per mL. As a result, propofol can significantly contribute to caloric intake and can potentially result in complications of overfeeding for patients who receive concurrent enteral or parenteral nutrition therapy. In order to avoid potential overfeeding, some clinicians have empirically decreased the infusion rate of the nutrition therapy, which also may have detrimental effects since protein intake may be inadequate. The purpose of this review is to examine the current literature regarding these issues and provide some practical suggestions on how to restrict caloric intake to avoid overfeeding and simultaneously enhance protein intake for patients who receive either parenteral or enteral nutrition for those patients receiving concurrent propofol therapy.