Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes

Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and proimmune properties; however, their use has not been rigorously studied in human TBI populations. A single-center, retrospective, descriptive observational study was conducted at the LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared with those who received standard, polymeric EN with regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.

Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes

Background

Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations.

Methods

A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes.

Results

A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI.

Conclusion

This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.

Isocaloric nutritional support reduces ventilator duration time in major trauma patients

AIMS

Major trauma patients need adequate nutrition for recovery. This study aimed to evaluate the adequacy of nutritional supply and the correlation between nutritional supply and clinical outcome.

METHODS

A single-centre retrospective observational study was undertaken, describing the amounts of energy and proteins provided to 320 critically ill trauma patients during the first 10 days after admission. The data were collected from the electronic medical records of patients admitted to the trauma intensive care unit during the study period and descriptive statistical analyses were performed with the SPSS software.

RESULTS

The mean proportion of supplied energy to recommended energy during the first 10 days after admission was 57.5%, and the mean percentage of supplied protein to recommended protein intake was 51.3%. The patients were divided into those who received ≥70% (isocaloric nutrition group) and those who received <70% (hypocaloric nutrition group) of their estimated requirements. Both the duration of ventilator use (12.7 ± 10.5 vs. 16.0 ± 15.8 days, respectively, p = 0.009) and duration of parenteral nutrition (1.1 ± 1.4 vs. 2.0 ± 2.0 days, respectively, p = 0.001) were shorter in the isocaloric nutrition group (n = 83) than in the hypocaloric nutrition group (n = 237).

CONCLUSION

Total energy and the amount of protein supplied were insufficient compared to the recommended amount. The duration of ventilator use was shorter in the isocaloric nutrition group than in the hypocaloric nutrition group. The association between shortened ventilator use and isocaloric nutrition requires further investigation as a potential intervention to reduce the risk of complications such as ventilator-related pneumonia.

Impact of early enteral nutrition on ventilator associated pneumonia in intubated severe trauma patients: A propensity score-matched study

Background

Early enteral nutrition (EN) is recommended for critically ill patients. However, the impact of early EN on intubated severe trauma patients remains unclear.

Methods

Severely traumatized adult patients who received invasive mechanical ventilation (MV) for more than 48 h during intensive care unit (ICU) stay at our institution between 2017 and 2022 were retrospectively included. Early EN was defined as EN initiation ≤48 h from ICU admission and late EN >48 h. Propensity score matching (PSM) analysis was used to compare outcomes between the groups. The primary endpoint was the incidence of ventilator-associated pneumonia (VAP). Multivariable logistic regression analysis was performed to identify independent predictors of delayed EN.

Results

For final analysis, 337 intubated severe trauma patients were available, including 204 (60.5%) in the early EN group and 133 (39.5%) in the late EN group. After PSM, early EN patients had a lower incidence of VAP (12.9 vs. 25.8%, p = 0.026) and a shorter length of hospital stay (21 vs. 24 days, p = 0.015) compared to late EN patients. There was no demonstrable difference in mortality between the two groups. Abdominal trauma, massive blood transfusion, and serum albumin were identified as independent risk factors for delayed EN.

Conclusion

Early EN decreased the VAP rate and reduced the length of hospital stay in invasively ventilated patients with severe trauma. Abdominal injury, massive blood transfusion and low albumin were associated with delayed EN.

Association between early ondansetron administration and in-hospital mortality in critically ill patients: analysis of the MIMIC-IV database

Background

While ondansetron (OND) is widespread availability, the contribution of OND to improve patient outcomes among intensive care unit (ICU) patients has not been examined. This study aimed to illustrate the association between early OND use and in-hospital mortality in critically ill patients and investigate whether this association differed according to OND dose.

Methods

The MIMIC-IV database was employed to identify patients who had and had not received OND. Statistical approaches included multivariate logistic regression, propensity score matching (PSM), and propensity score-based inverse probability of treatment weighting (IPTW) models to ensure the robustness of our findings.

Results

In total, 51,342 ICU patients were included. A significant benefit in terms of in-hospital mortality was observed in the OND patients compared to the non-OND group in the early stage [odds ratio (OR) = 0.75, 95% CI 0.63–0.89, p < 0.001]. In the circulatory system group, the early OND administration was associated with improved in-hospital mortality in ICU patients (OR 0.48, 95% CI 0.34–0.66; P < 0.001). The risk of in-hospital mortality was also lower in early OND users than in non-OND users both in the medical admission group and the surgical ICU admission group, and ORs were 0.57 (95% CI 0.42–0.76; P < 0.001) and 0.79 (95% CI 0.62–0.91; P < 0.001), respectively.

A positive role of daily low- and moderate-dose OND treatment in early-stage was showed on the in-hospital mortality in PSM cohort, and the ORs were 0.75 (95% CI 0.62–0.90; P < 0.001) and 0.63 (95% CI 0.43–0.91; P < 0.001), respectively. The relationship between the daily low- and moderate-dose of OND and in-hospital mortality was also significant in ICU patients with cardiovascular diseases, and ORs were 0.51(95% CI 0.36–0.73; P < 0.001), and 0.26(95% CI 0.11–0.65; P < 0.001), respectively. Daily low-to-moderate dose of OND was also associated with in-hospital mortality in ICU entire cohort.

Conclusions

Early OND use is closely associated with lower in-hospital mortality in ICU patients. Daily low-to-moderate dose of OND application is protective against in-hospital mortality. This association is more evident in the circulatory system group.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03401-y.

Bronchoscopy in intubated and non-intubated intensive care unit patients with respiratory failure

Bronchoscopy is one of the important tool for the pulmonary and critical care physicians to diagnose and treat various pulmonary conditions. It is increasingly being used by the intensivist due to its safety and portability. The utilization of bronchoscopy in the intensive care unit (ICU) has made the diagnosis and treatment of many conditions more feasible to intensivists. Sedation, topical or intravenous, usually helps better tolerate the procedure. However, the risks and benefits of bronchoscopy should be carefully considered in critically ill patients. The hypoxic patients in ICU pose a challenge as hypoxemia is one of the known complications of bronchoscopy, and this risk is exacerbated in patients with hypoxic respiratory failure. Bronchoscopy is relatively contraindicated in patients with severe hypoxemia and coagulopathy. However, bronchoscopy in hypoxic patients can have diagnostic as well as therapeutic implications. In patients with hypoxic respiratory failure, the use of non-invasive ventilation (NIV) during bronchoscopy has been shown to reduce the risk of intubation. On the other hand, bronchoscopy in mechanically ventilated patients is not contraindicated and has been widely used. Staying focused, monitoring vital signs closely, limiting the scope time in the airway, and understanding patient’s physiology may help decrease risk of complications. In this review, we discuss indications, techniques, complications, and yield associated with bronchoscopy in critically ill hypoxic patients.

Establishment and Verification of a Prediction Model for Symptomatic Radiation Pneumonitis in Patients with Esophageal Cancer Receiving Radiotherapy

BACKGROUND This study aimed to determine the value of the significant index in predicting symptomatic radiation pneumonitis (RP) in esophageal cancer patients, establish a nomogram prediction model, and verify the model. MATERIAL AND METHODS The patients enrolled were divided into 2 groups: a model group and a validation group. According to the logistic regression analysis, the independent predictors for symptomatic RP were obtained, and the nomogram prediction model was established according to these independent predictors. The consistency index (C-index) and calibration curve were used to evaluate the accuracy of the model, and the prediction ability of the model was verified in the validation group. Recursive partitioning analysis (RPA) was used for the risk stratification analysis. RESULTS The ratio of change regarding the pre-albumin at the end of treatment (P=0.001), platelet-to-lymphocyte ratio during treatment (P=0.027), and neutrophil-to-lymphocyte ratio at the end of treatment (P=0.001) were the independent predictors for symptomatic RP. The C-index of the nomogram model was 0.811. According to the risk stratification of RPA, the whole group was divided into 3 groups: a low-risk group, a medium-risk group, and a high-risk group. The incidence of symptomatic RP was 0%, 16.9%, and 57.6%, respectively. The receiver operating characteristic curve also revealed that the nomogram model has good accuracy in the validation group. CONCLUSIONS The developed nomogram and corresponding risk classification system have superior prediction ability for symptomatic RP and can predict the occurrence of RP in the early stage.

Effects of the Glutamine Administration on T Helper Cell Regulation and Inflammatory Response in Obese Mice Complicated with Polymicrobial Sepsis

This study investigated the impacts of GLN on inflammation and T cell dysregulation in obese mice complicated with sepsis. Mice were divided into normal control (NC) and high-fat diet groups. The high-fat diet provided 60% of energy from fat and was administered for 10 weeks to induce obesity. Mice fed with a high-fat diet were then assigned to sham (SH) and sepsis with saline (SS) or GLN (SG) groups. The SH group was subjected to laparotomy, while the sepsis group underwent cecal ligation and puncture (CLP). The SS group was intravenously injected with saline. The SG group was intravenously administered GLN after CLP. Mice were sacrificed at 12, 24, or 48 h post-CLP, respectively. Results demonstrated that in the presence of obesity, sepsis drove CD4+ T cells toward the helper T (Th)2 and Th17 lineages. Also, expressions of inflammatory cytokines and macrophage infiltration markers in adipose tissues and lungs were elevated. Treatment of obese mice with GLN after sepsis reversed Th polarization and downregulated macrophage infiltration and inflammatory cytokine, whereas the tight junction-associated protein expression increased in the lungs. These findings suggest that the intravenous administration of GLN to obese mice after sepsis modulated a more balanced Th cell lineage, alleviated inflammation, and attenuated lung injury.

A Volume-Based Feeding Protocol Improves Nutrient Delivery and Glycemic Control in a Surgical Trauma Intensive Care Unit

BACKGROUND

Inadequate delivery of nutrition in critically ill patients has been shown to have adverse outcomes. A surgical trauma intensive care unit provides unique challenges to enteral feeds. Although volume-based feeding protocols, like Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP), have been successfully used in medical intensive care patients, data are sparse on its safety and efficacy in a surgical intensive care unit population.

METHODS

A PEP uP protocol was recently initiated at our American College of Surgeons Level 1 verified trauma center. Medical records of 197 patients before this change (pre-PEP uP) were compared with 295 patients after this change (post-PEP uP).

RESULTS

The post-PEP uP group met/exceeded energy goals (defined as 80% of target) more often (57.0% compared with 26.9%, P-value < .001), with an adjusted odds ratio (OR) of 4.98 (95% CI 3.49-7.10), and more often met/exceeded protein goals (57.4% compared with 18.6%, P-value < .001), with an adjusted OR of 11.84 (95% CI 7.94-17.64). There was no significant difference in emesis during this time. Additionally, patients in the post-PEP uP arm had less episodes of hyperglycemia (9% compared with 14.4%, P-value < .001).

CONCLUSIONS

Volume-based feeding protocols like PEP uP are safe in critically ill trauma patients and are more effective at delivering energy and protein while limiting hyperglycemic episodes when compared with a traditional delivery method.

Impact of protein intake and nutritional status on the clinical outcome of critically ill patients

OBJECTIVE

To evaluate the association of nutritional status and protein intake with the clinical outcomes of critically ill patients receiving enteral nutrition therapy in an intensive care unit.

METHODS

A retrospective observational analytical study was performed by collecting secondary data recorded in medical records of patients ≥ 18 years of age who were admitted to the intensive care unit and who received exclusive enteral nutrition therapy for at least 72 hours in 2017. Nutritional status was assessed by body mass index and arm circumference. For the estimation of protein requirements, the recommendation of the American Society for Parenteral and Enteral Nutrition was considered. Nutritional adequacy was assessed by the daily collection of prescribed and administered enteral formula. In the analyses, parametric and nonparametric tests were used, and significance was set at p <0.05.

RESULTS

Of the 188 patients evaluated, 71.3% were male. The median age of the patients was 48.5 years (31.0 - 63.75). The main clinical diagnosis was trauma (46.3%), and eutrophic was the most frequent nutritional status (54.8% according to body mass index and 46.4% according to arm circumference). Protein adequacy was not attained in 56.4% of patients, and only 46.8% reached the minimum protein recommendation. The occurrence of mortality was associated with nutritional diagnosis, body mass index (p = 0.023), arm circumference (p = 0.041) and protein adequacy (p = 0.012).

CONCLUSION

Nutritional status and protein intake were significantly associated with the clinical outcomes of critically ill patients.

PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial

BACKGROUND

The Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP) has been shown to be feasible, safe, and effective in delivering significantly more energy/protein, though it has not been well studied in surgical/trauma patients. We hypothesized that PEP uP will effectively increase energy/protein delivery to critically ill surgical/trauma patients.

METHODS

This multicenter, prospective, randomized pilot study included adult patients admitted to surgical service who were expected to require mechanical ventilation for >24 hours and intensive care unit (ICU) care for >72 hours. Subjects were randomized to PEP uP or standard care. The PEP uP protocol includes initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24-hour volume-based goals, and modular protein supplementation. The primary outcome was nutrition adequacy over the first 12 ICU days.

RESULTS

Thirty-six subjects were enrolled. Slow recruitment resulted in early trial termination by the sponsor. There were no baseline differences between groups. PEP uP patients received more protein (106.8 ± 37.0 vs 78.5 ± 30.3 g/d, P = 0.02). Energy delivery was not significantly different (1400.0 ± 409.5 vs 1237.9 ± 459.1 kcal, P = 0.25). Vomiting was more common in the PEP uP patients (32% vs 12%, P = 0.03). PEP uP protocol violations included 2 patients (15.4%) not receiving pro-motility medications, 3 (23.1%) not receiving volume-based feeds as ordered, and 4 (30.8%) not receiving supplemental protein.

CONCLUSIONS

In surgical/trauma patients, PEPuP seemed to improve protein delivery but was difficult to implement successfully and may increase vomiting rates.

Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique

Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.

Volume-based feeding improves nutritional adequacy in surgical patients

BACKGROUND

Critically ill surgical patients often receive inadequate enteral nutrition using traditional rate-based feeding methods. An alternative strategy is volume-based feeding, in which feeding rates are adjusted to deliver a goal volume per day.

METHODS

This prospective quality improvement study in a single surgical, trauma, and burn ICU compared volume-based feeding to rate-based feeding in a before-and-after design. Outcomes included calories and protein delivered, length of stay, infection, and mortality.

RESULTS

A total of 50 patients received volume-based feeding and 49 rate-based feeding. The volume-based group received a higher proportion of goal calories (84.5% vs. 73.4%; p = 0.005) and protein (86.2% vs. 77.4%; p = 0.01), as well as increased total daily calories (1604 vs. 1356 kcal; p = 0.02). There was no difference in length of stay, mortality, aspiration, or gastrointestinal intolerance.

CONCLUSIONS

Volume-based feeding improved nutritional intake in critically ill surgical patients, although this study was underpowered to determine differences in clinical outcomes.