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Matsui R, Sagawa M, Sano A, Sakai M, Hiraoka SI, Tabei I, Imai T, Matsumoto H, Onogawa S, Sonoi N, Nagata S, Ogawa R, Wakiyama S, Miyazaki Y, Kumagai K, Tsutsumi R, Okabayashi T, Uneno Y, Higashibeppu N, Kotani J. Impact of Perioperative Immunonutrition on Postoperative Outcomes for Patients Undergoing Head and Neck or Gastrointestinal Cancer Surgeries: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2024; 279:419-428. [PMID: 37882375 PMCID: PMC10829905 DOI: 10.1097/sla.0000000000006116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To clarify whether perioperative immunonutrition is effective in adult patients with or without malnutrition undergoing elective surgery for head and neck (HAN) or gastrointestinal (GI) cancers. BACKGROUND It is important to avoid postoperative complications in patients with cancer as they can compromise clinical outcomes. There is no consensus on the efficacy of perioperative immunonutrition in patients with or without malnutrition undergoing HAN or GI cancer surgery. MATERIALS AND METHODS We searched MEDLINE (PubMed), MEDLINE (OVID), EMBASE, Cochrane Central Register of Controlled Trials, Web of Science Core Selection, and Emcare from 1981 to 2022 using search terms related to immunonutrition and HAN or GI cancer. We included randomized controlled trials. Intervention was defined as immunonutritional therapy including arginine, n-3 omega fatty acids, or glutamine during the perioperative period. The control was defined as standard nutritional therapy. The primary outcomes were total postoperative and infectious complications, defined as events with a Clavien-Dindo classification grade ≥ II that occurred within 30 days after surgery. RESULTS Of the 4825 patients from 48 included studies, 19 had upper GI cancer, 9 had lower, and 8 had mixed cancer, whereas 12 had HAN cancers. Immunonutrition reduced the total postoperative complications (relative risk ratio: 0.78; 95% CI, 0.66-0.93; certainty of evidence: high) and infectious complications (relative risk ratio: 0.71; 95% CI, 0.61-0.82; certainty of evidence: high) compared with standard nutritional therapy. CONCLUSIONS Nutritional intervention with perioperative immunonutrition in patients with HAN and GI cancers significantly reduced total postoperative complications and infectious complications.
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Affiliation(s)
- Ryota Matsui
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Ariake, Koto, Tokyo, Japan
| | - Masano Sagawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Tokyo Women’s Medical University Adachi Medical Center, Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Akihiko Sano
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of General Surgical Science, Division of Gastroenterological Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Makoto Sakai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of General Surgical Science, Division of Gastroenterological Surgery, Gunma University, Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shin-ichiro Hiraoka
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- 1st Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Osaka University, Suita, Osaka, Japan
| | - Isao Tabei
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, The Jikei University School of Medicine, Daisan Hospital, Minato-ku, Tokyo, Japan
| | - Takayuki Imai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Hideo Matsumoto
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Public Mitsugi General Hospital, Onomichi, Hiroshima, Japan
| | - Seiji Onogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Hiroshima, Japan
| | - Norihiro Sonoi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Center for Education in Medicine and Health Sciences, Okayama University Kita Ward, Okayama, Japan
| | - Shigeyuki Nagata
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Naka Ward, Hiroshima, Japan
| | - Ryo Ogawa
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Mizuho-cho, Mizuho-ku Nagoya, Japan
| | - Shigeki Wakiyama
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery, Machida Municipal Hospital, Nagoya-shi, Aichi, Japan
| | - Yasuhiro Miyazaki
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Osaka General Medical Center, Sumiyoshi Ward, Osaka, Japan
| | - Koshi Kumagai
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Ariake, Koto, Tokyo, Japan
| | - Rie Tsutsumi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Nutrition and Metabolism, Institute of Health Biosciences, Tokushima University Graduate School, Kuramoto-cho, Tokushima, Japan
| | - Takehiro Okabayashi
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kohasu, Oko-cho, Nankoku-shi, Kochi, Japan
| | - Yu Uneno
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, Japan
| | - Naoki Higashibeppu
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Minatojima Minamimachi, Chuo-ku, Kobe City, Japan
| | - Joji Kotani
- The Guidelines Committee, Japanese Society for Clinical Nutrition and Metabolism, Chuo-ku, Tokyo, Japan
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Chuo-ward, Kobe, Japan
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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3
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Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients 2022; 14:nu14050919. [PMID: 35267894 PMCID: PMC8912377 DOI: 10.3390/nu14050919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.
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Wang D, Lin Z, Xie L, Huang K, Ji Z, Gu C, Wang S. Impact of early protein provision on the mortality of acute critically ill stroke patients. Nutr Clin Pract 2021; 37:861-868. [PMID: 34582584 DOI: 10.1002/ncp.10768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Stroke is the leading cause of death in China, and dysphagia is a common symptom of stroke. For acute critically ill stroke patients, whether the protein provision overwhelming calorie provision impacts the outcome still requires investigation. MATERIALS AND METHODS We conducted a retrospectively observational study. Acute stroke patients admitted to our neurocritical care unit between January 2013 and January 2017 were enrolled. Primary end points were short-term (30-day) and long-term (6-month) mortality, as well as long-term poor outcome with a modified Rankin scale score ≥4. RESULTS Of 208 eligible patients, 127 (61.1%) patients were diagnosed with acute ischemic stroke and 81 (38.9%) with intracranial hemorrhage. In multivariate logistic regression analysis, the increased protein provision was significantly associated with reduced 30-day and 6-month mortality (P = .041 and P = .020, respectively) but not 6-month functional outcome (P = .365), whereas calorie provision had no independent association with either mortality or functional outcome. When the protein provision ≤1.74 g/kg/day, there was a 9.37% decrease in short-term mortality and a 9.21% decrease in long-term mortality with each 0.1 g/kg/day increase in protein delivery. The patients were further divided into five subgroups based on the amount of protein provision, and Linear-by-Linear Association tests showed there was a negative linear relationship between the protein provision and 30-day and 6-month mortality (P = .048 and P = .017, respectively). CONCLUSIONS Early protein provision during the first week is an independent predictor of short-term and long-term mortality in acute critically ill stroke patients.
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Affiliation(s)
- Dongmei Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhou Lin
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Xie
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Kaibin Huang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhong Ji
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chunping Gu
- Pharmaceutics Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
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5
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Hew JJ, Parungao RJ, Mooney CP, Smyth JK, Kim S, Tsai KHY, Shi H, Chong C, Chan RCF, Attia B, Nicholls C, Li Z, Solon-Biet SM, Le Couteur DG, Simpson SJ, Jeschke MG, Maitz PK, Wang Y. Low-protein diet accelerates wound healing in mice post-acute injury. BURNS & TRAUMA 2021; 9:tkab010. [PMID: 34377708 PMCID: PMC8350350 DOI: 10.1093/burnst/tkab010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/06/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Wound healing processes are influenced by macronutrient intake (protein, carbohydrate and fat). The most favourable diet for cutaneous wound healing is not known, although high-protein diets are currently favoured clinically. This experimental study investigates the optimal macronutrient balance for cutaneous wound healing using a mouse model and the Geometric Framework, a nutrient modelling method, capable of analyzing the individual and interactive effects of a wide spectrum of macronutrient intake. METHODS Two adjacent and identical full-thickness skin excisions (1 cm2) were surgically created on the dorsal area of male C57BL/6 mice. Mice were then allocated to one of 12 high-energy diets that varied in protein, carbohydrate and fat content. In select diets, wound healing processes, cytokine expression, energy expenditure, body composition, muscle and fat reserves were assessed. RESULTS Using the Geometric Framework, we show that a low-protein intake, coupled with a balanced intake of carbohydrate and fat is optimal for wound healing. Mice fed a low-protein diet progressed quickly through wound healing stages with favourable wound inflammatory cytokine expression and significantly accelerated collagen production. These local processes were associated with an increased early systemic inflammatory response and a higher overall energy expenditure, related to metabolic changes occurring in key macronutrient reserves in lean body mass and fat depots. CONCLUSIONS The results suggest that a low-protein diet may have a greater potential to accelerate wound healing than the current clinically used high-protein diets.
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Affiliation(s)
- Jonathan J Hew
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Roxanne J Parungao
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Craig P Mooney
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Julian K Smyth
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Sarah Kim
- Bone Biology Group, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Kevin H-Y Tsai
- Adrenal Steroids Laboratory, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Huaikai Shi
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Cassandra Chong
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Renee C F Chan
- Electron Microscopy Unit, Anatomical Pathology, Concord Hospital, Sydney, Australia 2139
| | - Beba Attia
- Electron Microscopy Unit, Anatomical Pathology, Concord Hospital, Sydney, Australia 2139
| | - Caroline Nicholls
- Burns Unit, Concord Repatriation General Hospital, Concord, Australia 2139
| | - Zhe Li
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
- Burns Unit, Concord Repatriation General Hospital, Concord, Australia 2139
| | - Samantha M Solon-Biet
- Ageing and Alzheimer Institute and ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
- Charles Perkins Centre and School of Life and Environmental Sciences, University of Sydney, Australia 2006
| | - David G Le Couteur
- Ageing and Alzheimer Institute and ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
| | - Stephen J Simpson
- Charles Perkins Centre and School of Life and Environmental Sciences, University of Sydney, Australia 2006
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, Ontario, Canada, M4N 3M5
| | - Peter K Maitz
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
- Burns Unit, Concord Repatriation General Hospital, Concord, Australia 2139
| | - Yiwei Wang
- Burns Research and Reconstructive Surgery, ANZAC Research Institute, Concord Hospital, University of Sydney, Sydney, Australia 2139
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, PR China 210023
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Al-Yousif N, Rawal S, Jurczak M, Mahmud H, Shah FA. Endogenous Glucose Production in Critical Illness. Nutr Clin Pract 2021; 36:344-359. [PMID: 33682953 DOI: 10.1002/ncp.10646] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Regulation of endogenous glucose production (EGP) by hormonal, neuronal, and metabolic signaling pathways contributes to the maintenance of euglycemia under normal physiologic conditions. EGP is defined by the generation of glucose from substrates through glycogenolysis and gluconeogenesis, usually in fasted states, for local and systemic use. Abnormal increases in EGP are noted in patients with diabetes mellitus type 2, and elevated EGP may also impact the pathogenesis of nonalcoholic fatty liver disease and congestive heart failure. In this narrative review, we performed a literature search in PubMed to identify recently published English language articles characterizing EGP in critical illness. Evidence from preclinical and clinical studies demonstrates that critical illness can disrupt EGP through multiple mechanisms including increased systemic inflammation, counterregulatory hormone and catecholamine release, alterations in the hypothalamic-pituitary axis, insulin resistance, lactic acidosis, and iatrogenic insults such as vasopressors and glucocorticoids administered as part of clinical care. EGP contributes to hyperglycemia in critical illness when abnormally elevated and to hypoglycemia when abnormally depressed, each of which has been independently associated with increased mortality. Increased EGP may also promote protein catabolism that could worsen critical illness myopathy and impede recovery. Better understanding of the mechanisms and factors contributing to dysregulated EGP in critical illness may help in the development of therapeutic strategies that promote euglycemia, reduce intensive care unit-associated catabolism, and improve patient outcomes.
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Affiliation(s)
- Nameer Al-Yousif
- Department of Internal Medicine, UPMC Mercy Hospital, Pittsburgh, Pennsylvania, USA
| | - Sagar Rawal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Jurczak
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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7
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Jiang H, Zhang JC, Zeng J, Wang L, Wang Y, Lu CD, Deng L, Deng H, Wang K, Sun MW, Zhou P, Yuan T, Chen W. Gut, metabolism and nutritional Support for COVID-19: Experiences from China. BURNS & TRAUMA 2020; 8:tkaa048. [PMID: 33654695 PMCID: PMC7901705 DOI: 10.1093/burnst/tkaa048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 11/23/2020] [Indexed: 12/22/2022]
Abstract
There is little research that focuses on the relationship between the gut, metabolism, nutritional support and COVID-19. As a group of Chinese physicians, nutritionists and scientists working on the frontline treating COVID-19 patients, we aim to integrate our experiences and the current clinical evidence to address this pressing issue in this article. Based on our clinical observations and available evidence, we recommend the following practice. Firstly, the Nutritional Risk Screening 2002 tool should be used routinely and periodically; for patients with a score ≥3, oral nutritional supplements should be given immediately. Secondly, for patients receiving the antiviral agents lopinavir/ritonavir, gastrointestinal side effects should be monitored for and timely intervention provided. Thirdly, for feeding, the enteral route should be the first choice. In patients undergoing mechanical ventilation, establishing a jejunal route as early as possible can guarantee the feeding target being achieved if gastric dilatation occurs. Fourthly, we suggest a permissive underfeeding strategy for severe/critical patients admitted to the intensive care unit during the first week of admission, with the energy target no more than 20 kcal/kg/day (for those on mechanical ventilation, this target may be lowered to 10-15 kcal/kg/day) and the protein target around 1.0-1.2 g/kg/day. If the inflammatory condition is significantly alleviated, the energy target may be gradually increased to 25-30 kcal/kg/day and the protein target to 1.2-1.5 g/kg/day. Fifthly, supplemental parenteral nutrition should be used with caution. Lastly, omega-3 fatty acids may be used as immunoregulators, intravenous administration of omega-3 fatty emulsion (10 g/day) at an early stage may help to reduce the inflammatory reaction.
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Affiliation(s)
- Hua Jiang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Jian-Cheng Zhang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Jun Zeng
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Lu Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Yu Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Charles Damien Lu
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Lei Deng
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Medical Task Force of Sichuan Provincial People’s Hospital to Union Red Cross Hospital of Wuhan, Wuhan, 430015, China
| | - Hongfei Deng
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Kai Wang
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ming-Wei Sun
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Department of Acute Care Surgery, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32, Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ping Zhou
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
- Emergency Intensive Care Unit, Emergency Medicine Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Ting Yuan
- Institute for Emergency Medicine and Disaster Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Yi Huan Lu Xi Er Duan, Chengdu, 610072, Sichuan Province, China
| | - Wei Chen
- Department of Clinical Nutrition, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuai fu yuan Wang fu jing Dong cheng District, Beijing, 100730, China
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8
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Deane AM, Ali Abdelhamid Y, Plummer MP, Fetterplace K, Moore C, Reintam Blaser A. Are Classic Bedside Exam Findings Required to Initiate Enteral Nutrition in Critically Ill Patients: Emphasis on Bowel Sounds and Abdominal Distension. Nutr Clin Pract 2020; 36:67-75. [PMID: 33296117 DOI: 10.1002/ncp.10610] [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: 07/26/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023] Open
Abstract
The general physical examination of a patient is an axiom of critical care medicine, but evidence to support this practice remains sparse. Given the lack of evidence for a comprehensive physical examination of the entire patient on admission to the intensive care unit, which most clinicians consider an essential part of care, should clinicians continue the practice of a specialized gastrointestinal system physical examination when commencing enteral nutrition in critically ill patients? In this review of literature related to gastrointestinal system examination in critically ill patients, the focus is on gastrointestinal sounds and abdominal distension. There is a summary of what these physical features represent, an evaluation of the evidence regarding use of these physical features in patients after abdominal surgery, exploration of the rationale for and against using the physical findings in routine practice, and detail regarding what is known about each feature in critically ill patients. Based on the available evidence, it is recommended that an isolated symptom, sign, or bedside test does not provide meaningful information. However, it is submitted that a comprehensive physical assessment of the gastrointestinal system still has a role when initiating or administering enteral nutrition: specifically, when multiple features are present, clinicians should consider further investigation or intervention.
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Affiliation(s)
- Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, The University of Melbourne, Parkville, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark P Plummer
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, The University of Melbourne, Parkville, Victoria, Australia
| | - Kate Fetterplace
- Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, The University of Melbourne, Parkville, Victoria, Australia.,Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Cara Moore
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Department of Intensive Care, Lucerne Cantonal Hospital, Lucerne, Switzerland
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9
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Moretti D, Ré MD, Rocchetti NS, Bagilet DH, Settecase CJ, Buncuga MG, Quaglino MB. Value of the urea/creatinine index in isolated urine to estimate severe protein hypercatabolism in ventilated patients. Rev Bras Ter Intensiva 2020; 32:506-513. [PMID: 33470351 PMCID: PMC7853688 DOI: 10.5935/0103-507x.20200087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/27/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To study the ability of the urea/creatinine index to identify severe protein catabolism from the isolated urine of critically ventilated patients. Methods This was a prospective, observational study. It included 52 patients without kidney failure. Variables: total urinary nitrogen estimated from the urea in 24-hour urine on the second (T1) and fourth days (T2) and urea/creatinine index in isolated urine before 24-hour urine collection. Results Severe protein hypercatabolism (estimated total urinary nitrogen > 15g) was present in 14 patients (26.9%) at T1 and in 29 (55.7%) at T2. Eighty-four percent of patients had low nutritional risk by the Nutrition Risk in the Critically Ill score. At T1, the Pearson correlation between the estimated total urinary nitrogen and the urea/creatinine index was 0.272 (p = 0.051), and at T2 it was 0.276 (p = 0.048). The urea/creatinine index at T2 had a tendency to better discriminate severe protein hypercatabolism than Acute Physiology and Chronic Health Evaluation II and Nutrition Risk in the Critically Ill (AUC 0.741 versus 0.669 and 0.656, 95%CI: 0.602 - 0.880; 0.519 - 0.818 and 0.506 - 0.806, respectively). The optimal cutoff value of the urea/creatinine index for the diagnosis of severe protein hypercatabolism was 16.15, with a sensitivity of 79.31% (95%CI: 59.74 - 91.29), specificity of 60.87% (95%CI: 38.78 - 79.53), positive predictive value 71.88% (95%CI: 53.02 - 85.60), negative predictive value 70.0% (95%CI: 45.67 - 87.18), LR (+) 2.03 (95%CI: 1.18 - 3.49), and LR (-) 0.34 (95%CI: 0.16 - 0.74). Conclusion The urea/creatinine index measured on the fourth day has a certain ability to estimate severe protein hypercatabolism (as defined by estimated total urinary nitrogen) but does not replace total urinary nitrogen in critically ventilated patients without kidney failure. Due to its reasonable sensitivity, it could be used as a screen to identify which patients to take a 24-hour urine sample from.
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Affiliation(s)
- Dino Moretti
- Universidad Nacional de Rosario - Santa Fe, Argentina.,Unidad de Cuidados Intensivos, Hospital "Eva Perón" - Santa Fe, Argentina
| | - Melisa D Ré
- Universidad Nacional de Rosario - Santa Fe, Argentina.,Unidad de Cuidados Intensivos, Hospital "Eva Perón" - Santa Fe, Argentina
| | - Nicolás Sebastián Rocchetti
- Universidad Nacional de Rosario - Santa Fe, Argentina.,Unidad de Cuidados Intensivos, Hospital "Eva Perón" - Santa Fe, Argentina
| | - Daniel H Bagilet
- Universidad Nacional de Rosario - Santa Fe, Argentina.,Unidad de Cuidados Intensivos, Hospital "Eva Perón" - Santa Fe, Argentina
| | - Claudio Jesús Settecase
- Universidad Nacional de Rosario - Santa Fe, Argentina.,Unidad de Cuidados Intensivos, Hospital "Eva Perón" - Santa Fe, Argentina
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10
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Garcia MC, Surampudi V, Li Z, Saggar R, Shah S. Weight loss for critical care patient to improve lung transplantation candidacy: A case report. Respir Med Case Rep 2020; 31:101193. [PMID: 32874911 PMCID: PMC7451811 DOI: 10.1016/j.rmcr.2020.101193] [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: 05/23/2020] [Accepted: 08/11/2020] [Indexed: 10/27/2022] Open
Abstract
A 47-year-old male with morbid obesity and progressive pulmonary fibrosis was admitted to the intensive care unit (ICU) with worsening hypoxia and nocturnal ventilator dependence. Due to a significant oxygen requirement, the patient could only safely remain in an acute care setting. Unfortunately, he was not eligible for lung transplantation due to having obesity, a relative contraindication to lung transplantation due to potential for post transplantation complications and increased mortality. Therefore, we treated the patient with a modified very low calorie diet (MVLCD) to achieve weight loss. He had successful, sustained weight loss over a period of seven weeks and reached a target weight that made him eligible for transplantation. He subsequently underwent successful bilateral lung transplantation. The patient had improved metabolic parameters and no side effects attributable to the reduced calorie diet. This report shows that in patients with end stage lung disease and a poor prognosis without transplantation, inpatient weight loss is safe and may allow for potentially lifesaving lung transplantation.
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Affiliation(s)
- Michael C Garcia
- Center for Human Nutrition, Division of Clinical Nutrition, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vijaya Surampudi
- Center for Human Nutrition, Division of Clinical Nutrition, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Zhaoping Li
- Center for Human Nutrition, Division of Clinical Nutrition, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sapna Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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11
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Mitochondrial Dysfunction in Critical Illness: Implications for Nutritional Therapy. Curr Nutr Rep 2020; 8:363-373. [PMID: 31713718 DOI: 10.1007/s13668-019-00296-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF THE REVIEW This paper will review the evidence for mitochondrial dysfunction in critical illness, describe the mechanisms which lead to multiple organ failure, and detail the implications of this pathophysiologic process on nutritional therapy. RECENT FINDINGS Mitochondria are particularly sensitive to increased oxidative stress in critical illness. The functional and structural abnormalities which occur in this organelle contribute further to the excessive production of reactive oxygen species and the reduction in generation of adenosine triphosphate (ATP). To reduce metabolic demand, mitochondrial dysfunction develops (a process likened to hibernation), which helps sustain the life of the cell at a cost of organ system failure. Aggressive feeding in the early phases of critical illness might inappropriately increase demand at a time when ATP production is limited, further jeopardizing cell survival and potentiating the processes leading to multiple organ failure. Several potential therapies exist which would promote mitochondrial function in the intensive care setting through support of autophagy, antioxidant defense systems, and the biogenesis and recovery of the organelle itself. Nutritional therapy should supplement micronutrients required in the mitochondrial metabolic pathways and provide reduced delivery of macronutrients through slower advancement of feeding in the early phases of critical illness. A better understanding of mitochondrial dysfunction in the critically ill patient should lead to more innovative therapies in the future.
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12
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McKendry J, Thomas ACQ, Phillips SM. Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies. Nutr Clin Pract 2020; 35:607-616. [PMID: 32578900 DOI: 10.1002/ncp.10540] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022] Open
Abstract
Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.
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Affiliation(s)
- James McKendry
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Aaron C Q Thomas
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Stuart M Phillips
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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13
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ApSimon M, Johnston C, Winder B, Cohen SS, Hopkins B. Narrowing the Protein Deficit Gap in Critically Ill Patients Using a Very High-Protein Enteral Formula. Nutr Clin Pract 2020; 35:533-539. [PMID: 32083356 DOI: 10.1002/ncp.10472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Protein deficits have been associated with longer intensive care unit (ICU) stays and increased mortality. Current view suggests if protein goals are met, meeting full energy targets may be less important and prevent deleterious effects of overfeeding. We proposed a very-high protein (VHP) enteral nutrition (EN) formula could provide adequate protein, without overfeeding energy, in the first week of critical illness. METHODS This was a retrospective study of medical/surgical ICU patients receiving EN exclusively for ≥5 days during the first week of ICU admission. Twenty participants received standard EN; 20 participants received the VHP-EN formula (1 kcal/mL, 37% protein). Protein and energy prescribed/received, gastrointestinal tolerance, and feeding interruptions were examined. RESULTS Forty ICU patients [average Acute Physiology and Chronic Health Evaluation II score of 20.1] were included. Protein prescribed and received was significantly higher in the VHP group vs the standard EN group (135.5 g/d ± 22.9 vs 111.4 g/d ± 25; P = .003 and 112.2 g/d ± 27.8 vs 81.7 g/d ± 16.7, respectively; P = .002). Energy prescribed and received was similar between groups (1696 kcal/d ± 402 vs 1893 kcal/d ± 341, respectively; P = .101 and 1520 kcal/d ± 346 vs 1506 ± 380 kcal/d; P = .901). There were no differences in EN tolerance (P = .065) or feeding interruptions (P = .336). CONCLUSIONS Use of a VHP formula in ICU patients resulted in higher protein intakes without overfeeding energy or use of modular protein in the first 5 days of exclusive EN.
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Affiliation(s)
- Michele ApSimon
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | - Carrie Johnston
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | - Barb Winder
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | | | - Bethany Hopkins
- Medical Affairs, Nestlé Health Science Canada, North York, Ontario, Canada
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14
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15
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McClave SA, Gualdoni J, Nagengast A, Marsano LS, Bandy K, Martindale RG. Gastrointestinal Dysfunction and Feeding Intolerance in Critical Illness: Do We Need an Objective Scoring System? Curr Gastroenterol Rep 2020; 22:1. [PMID: 31912312 DOI: 10.1007/s11894-019-0736-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Efforts to provide early enteral nutrition in critical illness are thwarted by gastrointestinal dysfunction and feeding intolerance. While many of the signs and symptoms of this dysfunction reflect gastroparesis and intestinal dysmotility, other symptoms which may or may not be related are often included such as diarrhea, bleeding, and intra-abdominal hypertension. This paper discusses the need to monitor tolerance of nutritional therapy in the critical care setting and reviews the results of those clinical trials which have helped establish objective measures, define feeding intolerance, and provide a tool to guide continued delivery of the enteral regimen. RECENT FINDINGS While definitions vary, the presence of gastrointestinal dysfunction and feeding intolerance correlates with adverse clinical outcomes, including prolonged duration of mechanical ventilation, greater length of stay in the intensive care unit, and increased mortality. Despite their prognostic value, it is not clear to what extent these scoring systems should direct nutritional therapy. The clinician should be astute in the careful selection of monitors, in identifying and addressing signs and symptoms of intolerance, and by responding appropriately with feeding strategies that are effective and safe. Early enteral feeding in critical illness has been shown to be optimized by following protocols which allow monitoring patient tolerance while providing individualized care.
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Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA.
- Division of Gastroenterology, Hepatology & Nutrition, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY, 40202, USA.
| | - Jill Gualdoni
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Annie Nagengast
- Department of Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Luis S Marsano
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Kathryn Bandy
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
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16
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Vest MT, Newell E, Shapero M, McGraw P, Jurkovitz C, Lennon SL, Trabulsi J. Energy balance in obese, mechanically ventilated intensive care unit patients. Nutrition 2019; 66:48-53. [PMID: 31207439 PMCID: PMC6702036 DOI: 10.1016/j.nut.2019.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/06/2019] [Accepted: 02/24/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aims of this study were, first, to compare the predicted (calculated) energy requirements based on standard equations with target energy requirement based on indirect calorimetry (IC) in critically ill, obese mechanically ventilated patients; and second, to compare actual energy intake to target energy requirements. METHODS We conducted a prospective cohort study of mechanically ventilated critically ill patients with body mass index ≥30.0 kg/m2 for whom enteral feeding was planned. Clinical and demographic data were prospectively collected. Resting energy expenditure was measured by open-circuit IC. American Society of Parenteral and Enteral Nutrition (APSPEN)/Society of Critical Care Medicine (SCCM) 2016 equations were used to determine predicted (calculated) energy requirements. Target energy requirements were set at 65% to 70% of measured resting energy expenditure as recommended by ASPEN/SCCM. Nitrogen balance was determined via simultaneous measurement of 24-h urinary nitrogen concentration and protein intake. RESULTS Twenty-five patients (mean age: 64.5 ± 11.8 y, mean body mass index: 35.2 ± 3.6 kg/m2) underwent IC. The mean predicted energy requirement was 1227 kcal/d compared with mean measured target energy requirement of 1691 kcal/d. Predicted (calculated) energy requirements derived from ASPEN/SCCM equations were less than the target energy requirements in most cases. Actual energy intake from enteral nutrition met 57% of target energy requirements. Protein intake met 25% of target protein requirement and the mean nitrogen balance was -2.3 ± 5.1 g/d. CONCLUSIONS Predictive equations underestimated target energy needs in this population. Further, we found that feeding to goal was often delayed resulting in failure to meet both protein and energy intake goals.
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Affiliation(s)
- Michael T Vest
- Critical Care Medicine, Department of Medicine, Christiana Care Healthcare System, Christiana Care Value Institute, Newark, Delaware, USA, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA.
| | - Emma Newell
- Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware, USA
| | - Mary Shapero
- Department of Food and Nutrition Services, Christiana Care Healthcare System, Newark, Delaware, USA
| | - Patricia McGraw
- Department of Medicine Research, Christiana Care Healthcare System, Newark, Delaware, USA
| | | | - Shannon L Lennon
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, USA
| | - Jillian Trabulsi
- Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware, USA
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17
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Lew CCH, Wong GJY, Cheung KP, Fraser RJL, Chua AP, Chong MFF, Miller M. When timing and dose of nutrition support were examined, the modified Nutrition Risk in Critically Ill (mNUTRIC) score did not differentiate high-risk patients who would derive the most benefit from nutrition support: a prospective cohort study. Ann Intensive Care 2018; 8:98. [PMID: 30350233 PMCID: PMC6197342 DOI: 10.1186/s13613-018-0443-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 10/06/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The timing and dose of exclusive nutrition support (ENS) have not been investigated in previous studies aimed at validating the modified Nutrition Risk in Critically Ill (mNUTRIC) score. We therefore evaluated the mNUTRIC score by determining the association between dose of nutrition support and 28-day mortality in high-risk patients who received short- and longer-term ENS (≤ 6 days vs. ≥ 7 days). METHODS A prospective cohort study included data from 252 adult patients with > 48 h of mechanical ventilation in a tertiary care institution in Singapore. The dose of nutrition support (amount received ÷ goal: expressed in percentage) was calculated for a maximum of 14 days. Associations between the dose of energy (and protein) intake and 28-day mortality were evaluated with multivariable Cox regressions. Since patients have different durations of ENS, only the first 6 days of ENS in patients with short- and longer-term ENS were assessed in the Cox regressions to ensure a valid comparison of the associations between energy (and protein) intake and 28-day mortality. RESULTS In high-risk patients with short-term ENS (n = 106), each 10% increase in goal energy intake was associated with an increased hazard of 28-day mortality [adj-HR 1.37 (95% CI 1.17, 1.61)], and this was also observed for protein intake [adj-HR 1.31 (95% CI 1.10, 1.56)]. In contrast, each 10% increase in goal protein intake in high-risk patients with longer-term ENS (n = 146) was associated with a lower hazard of 28-day mortality [adj-HR 0.78 (95% CI 0.66, 0.93)]. The mean mNUTRIC scores in these two groups of patients were similar. CONCLUSION When timing and dose of nutrition support were examined, the mNUTRIC did not differentiate high-risk patients who would derive the most benefit from nutrition support.
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Affiliation(s)
- Charles Chin Han Lew
- Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001 Australia
- Dietetics and Nutrition Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Gabriel Jun Yung Wong
- Dietetics and Nutrition Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Ka Po Cheung
- Dietetics and Nutrition Department, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Robert J. L. Fraser
- Department of Gastroenterology and Hepatology, College of Medicine and Public Health, Flinders University, GPO Box 2100, Adelaide, SA 5001 Australia
| | - Ai Ping Chua
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606 Singapore
| | - Mary Foong Fong Chong
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Michelle Miller
- Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide, SA 5001 Australia
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Druml W. [Intestinal cross-talk : The gut as motor of multiple organ failure]. Med Klin Intensivmed Notfmed 2018; 113:470-477. [PMID: 30120495 DOI: 10.1007/s00063-018-0475-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 12/31/2022]
Abstract
The central role of the organ system "gut" for critically ill patients has not been acknowledged until the last decade. The gut is a crucial immunologic, metabolic and neurologic organ system and impairment of its functions is associated with morbidity and mortality. The gut has a central position in the cross-talk between organs and dysfunction of the gut may result in impairment of other intra-abdominal and extra-abdominal organ systems. The intestinal tract is the most important source of endogenous infections and determines the inflammatory status of the organism. Gut failure is an element of the multiple organ dysfunction syndrome (MODS). The leading mechanism in the evolution of endogenous infections is the intestinal translocation of microbes. A dysbiosis and damage of the intestinal mucosa leads to a disorder of the mucosal barrier function, increases the permeability and promotes translocation (leaky gut hypothesis). A further crucial mechanism of organ interactions is the increase in intra-abdominal pressure. Intra-abdominal hypertension promotes further injury of the gut, increases translocation and inflammation and causes dysfunction of other organ systems, such as the kidneys, the cardiovascular system and the lungs. Maintaining and/or restoring intestinal functions must be a priority of any intensive care therapy. The most important measure is early enteral nutrition. Other measures are the preservation of motility and modulation of the intestinal microbiome. Intra-abdominal hypertension must be reduced by an individually adapted infusion therapy, positioning of the patient, administration of drugs (abdominal compliance) and decompression (by tubes, endoscopically or in severe cases surgically).
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Affiliation(s)
- W Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
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Hoffer LJ. High-Protein Hypocaloric Nutrition for Non-Obese Critically Ill Patients. Nutr Clin Pract 2018; 33:325-332. [PMID: 29701916 DOI: 10.1002/ncp.10091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
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