1
|
Stolarski AE, Young L, Weinberg J, Kim J, Lusczek E, Remick DG, Bistrian B, Burke P. Early metabolic support for critically ill trauma patients: A prospective randomized controlled trial. J Trauma Acute Care Surg 2022; 92:255-265. [PMID: 34739002 PMCID: PMC8792201 DOI: 10.1097/ta.0000000000003453] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is a lack of consensus regarding the optimal nutritional support for trauma patients. We hypothesize that early postinjury metabolic support focusing on adequate protein would modify the metabolic signature and alter the inflammatory environment for critically ill trauma patients. METHODS We conducted a prospective randomized controlled pilot trial for adult patients admitted to the surgical intensive care unit following traumatic injury. Patients were randomized to receive early metabolic support (EMS) (peripheral amino acid infusions) or standard of care (enteral nutrition as soon as feasible). Routine laboratory assessments, nitrogen balance, cytokines, and metabolomic analyses were assessed at baseline and day 5 after intervention. RESULTS A total of 42 trauma patients were randomized into well-balanced groups with similar age (32 years), Injury Severity Score (25), and body mass index (27.4 kg/m2). Early metabolic support provided significantly more protein (1.43 g/kg vs. 0.35 g/kg; p < 0.0001) and more calories (12.6 kcal/kg vs. 7.5 g/kg; p = 0.0012) over the first 5 days as compared with the standard of care. Early metabolic support modified protein catabolism and synthesis as demonstrated by a larger median negative nitrogen balance (-16.3 g vs. -5.3 g; p = 0.03) and a unique metabolomic profile at day 5. The biochemical profile of patients who received EMS was defined by greater declines in circulating levels of stress hormone precursors and increased levels of amino acids. The inflammatory response following EMS resulted in a greater decrease in interleukin-1B (p = 0.02) and increase in soluble interleukin-6 receptor (p = 0.01) between baseline and day 5 as compared with the standard of care. The EMS group had a decreased length of stay (15 vs. 22 days) and decreased surgical intensive care unit length of stay (8 vs. 9 days); however, this disappeared after adjustment for Injury Severity Score in this small population. CONCLUSIONS Early metabolic support with amino acid is safe, modifies metabolism, and may downregulate the inflammatory state associated with significant trauma, warranting a larger trial to assess for improved outcomes. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
Collapse
Affiliation(s)
| | - Lorraine Young
- Department of Medicine, Boston Medical Center | Boston University
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health
| | - Jiyoun Kim
- Department of Pathology, Boston Medical Center | Boston University
| | | | - Daniel G. Remick
- Department of Pathology, Boston Medical Center | Boston University
| | - Bruce Bistrian
- Department of Medicine, Beth Israel Deaconess Medical Center
| | - Peter Burke
- Department of Surgery, Boston Medical Center | Boston University
| |
Collapse
|
2
|
Dickerson RN. Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice. Nutr Clin Pract 2020; 35:617-626. [PMID: 32588488 DOI: 10.1002/ncp.10501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.
Collapse
Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA
| |
Collapse
|
3
|
Dickerson RN. Metabolic support challenges with obesity during critical illness. Nutrition 2018; 57:24-31. [PMID: 30153576 DOI: 10.1016/j.nut.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/14/2018] [Accepted: 05/21/2018] [Indexed: 12/21/2022]
Abstract
Adiposity-based chronic disease, critical illness, and nutrition therapy increase the risk for overfeeding and worsened nutritional and clinical outcomes. Hypocaloric, high-protein nutrition therapy provides critically ill obese patients the opportunity to achieve net protein anabolism with a reduced risk for overfeeding-related complications. The intent of this review is to discuss the impact of obesity on clinical outcomes, describe the consequences of obesity that increase complications associated with nutrition therapy, provide the framework to develop a hypocaloric, high-protein regimen, review the scientific evidence to support this mode of therapy, and discuss its limitations. Practical suggestions for patient monitoring are also provided.
Collapse
Affiliation(s)
- Roland N Dickerson
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee.
| |
Collapse
|
4
|
Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
Collapse
Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
| | | |
Collapse
|
5
|
Validation of predictive equations to assess energy expenditure in acute spinal cord injury. J Trauma Acute Care Surg 2018; 85:984-991. [PMID: 29787541 DOI: 10.1097/ta.0000000000001959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute spinal cord injury (SCI) is devastating with morbidities compounded by inadequate nutrition. The American Society for Parenteral and Enteral Nutrition recommends indirect calorimetry (IC) to evaluate energy needs in SCI because no predictive energy equations have been validated. We sought to determine the accuracy of predictive equations to predict measured energy expenditure (MEE). METHODS A retrospective review was performed over 2 years. Patients 18 years or older with cervical SCI who received IC were included. Height, weight, maximum temperature and minute ventilation on day of IC, plus MEE and VCO2 from IC were obtained. Predicted energy expenditure (PEE) was calculated using Harris-Benedict (HB), Penn State (PS), Mifflin St. Jeor (MSJ), Weir, Ireton-Jones (IJ), and 25 kcal/kg formulas. MEE was then compared to the PEE of each method. RESULTS Thirty-nine IC studies were completed for 20 patients. Weir had the strongest correlation to MEE (r = 0.98), followed by PS (r = 0.82). Correlations were similar among HB (r = 0.78), MSJ (r = 0.75), and IJ (r = 0.73), and weakest with 24 kcal/kg (r = 0.55). All had a p value <0.001. Deming regression confirmed strong correlations between Weir and PS to MEE, with coefficients of 1.03 and 1.515 (p < 0.001), respectively. Other formulas had comparatively higher coefficients and standard errors. Bland-Altman analysis confirmed Weir had the narrowest range of difference, with a mean difference of 25.5 kcal/day, followed by PS (-336.1 kcal/day). CONCLUSIONS Weir is the best predictive energy equation, with all statistical tests demonstrating a strong correlation between MEE and Weir. The second best predictive equation is the Penn State formula, which predicts actual MEE measured by IC with high accuracy. LEVEL OF EVIDENCE Diagnostic study, level III.
Collapse
|
6
|
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.
Collapse
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| |
Collapse
|
7
|
Disorders of nutritional status in sepsis - facts and myths. GASTROENTEROLOGY REVIEW 2017; 12:73-82. [PMID: 28702094 PMCID: PMC5497135 DOI: 10.5114/pg.2017.68165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/28/2017] [Indexed: 12/18/2022]
Abstract
The problem of diagnosing nutritional status disorders in septic patients remains unresolved. This is associated with the necessity of the introduction of newer and newer methods of assessing nutritional status, often requiring precise and expensive equipment as well as employment of professionals in this field in hospital wards, primarily including intensive care units (ICU). Methods that have been applied thus far for assessing nutritional status, also used in severely ill septic patients, have little impact on improving treatment results. This is due to the high dynamics of changes in nutritional status in these patients, healing process variability in individual patients, and the “mismatch” of methods for assessing nutritional status in relation to the patient’s clinical status. The diagnostic value of the traditional methods of assessing nutritional status, i.e. anthropometric analysis and selected laboratory tests, as markers of nutritional status disorders in septic patients, is still debatable. There is still no precise method that could become the “gold standard” allowing for early identification of malnutrition in these group of patients. Phase angle, bioelectrical impedance vector analysis (BIVA), and the “illness marker”, obtained directly from the resistance, reactance, and impedance, can be used as prognostic or nutritional indices in severely ill septic patients, but the intensity of research on this subject needs to be increased. Detailed assessment of nutritional status should include tests of selected inflammation markers (including TLC, HMGB1, IL-6, IL-10, IL-1ra, sTNFRI).
Collapse
|
8
|
Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:358. [PMID: 27814776 PMCID: PMC5097427 DOI: 10.1186/s13054-016-1539-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/20/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND There is conflicting evidence about the relationship between the dose of enteral caloric intake and survival in critically ill patients. The objective of this systematic review and meta-analysis is to compare the effect of lower versus higher dose of enteral caloric intake in adult critically ill patients on outcome. METHODS We reviewed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through November 2015. We included randomized and quasi-randomized studies in which there was a significant difference in the caloric intake in adult critically ill patients, including trials in which caloric restriction was the primary intervention (caloric restriction trials) and those with other interventions (non-caloric restriction trials). Two reviewers independently extracted data on study characteristics, caloric intake, and outcomes with hospital mortality being the primary outcome. RESULTS Twenty-one trials mostly with moderate bias risk were included (2365 patients in the lower caloric intake group and 2352 patients in the higher caloric group). Lower compared with higher caloric intake was not associated with difference in hospital mortality (risk ratio (RR) 0.953; 95 % confidence interval (CI) 0.838-1.083), ICU mortality (RR 0.885; 95 % CI 0.751-1.042), total nosocomial infections (RR 0.982; 95 % CI 0.878-1.077), mechanical ventilation duration, or length of ICU or hospital stay. Blood stream infections (11 trials; RR 0.718; 95 % CI 0.519-0.994) and incident renal replacement therapy (five trials; RR 0.711; 95 % CI 0.545-0.928) were lower with lower caloric intake. The associations between lower compared with higher caloric intake and primary and secondary outcomes, including pneumonia, were not different between caloric restriction and non-caloric restriction trials, except for the hospital stay which was longer with lower caloric intake in the caloric restriction trials. CONCLUSIONS We found no association between the dose of caloric intake in adult critically ill patients and hospital mortality. Lower caloric intake was associated with lower risk of blood stream infections and incident renal replacement therapy (five trials only). The heterogeneity in the design, feeding route and timing and caloric dose among the included trials could limit our interpretation. Further studies are needed to clarify our findings.
Collapse
Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Intensive Care Department, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426, Saudi Arabia
| | | | - Mazen Ferwana
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Family Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,National & Gulf Center for Evidence Based Health Practice, Riyadh, 11426, Saudi Arabia
| | - Mohammad Hassan Murad
- Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA.,Preventive Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. .,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. .,Intensive Care Department, King Abdulaziz Medical City, P.O. Box 22490, Riyadh, 11426, Saudi Arabia.
| |
Collapse
|
9
|
Abstract
Critically ill people are unable to eat. What’s the best way to feed them? Nutrition authorities have long recommended providing generous amounts of protein and calories to critically ill patients, either intravenously or through feeding tubes, in order to counteract the catabolic state associated with this condition. In practice, however, patients in modern intensive care units are substantially underfed. Several large randomized clinical trials were recently carried out to determine the clinical implications of this situation. Contradicting decades of physiological, clinical, and observational data, the results of these trials have been claimed to justify the current practice of systematic underfeeding in the intensive care unit. This article explains and suggests how to resolve this conundrum.
Collapse
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Bruce R Bistrian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
10
|
Abstract
Malnutrition has been identified as a cause for disease as well as a condition resulting from inflammation associated with acute or chronic disease. Malnutrition is common in acute-care settings, occurring in 30% to 50% of hospitalized patients. Inflammation has been associated with malnutrition and malnutrition has been associated with compromised immune status, infection, and increased intensive care unit (ICU) and hospital length of stay. The ICU nurse is in the best position to advocate for appropriate nutritional therapies and facilitate the safe delivery of nutrition.
Collapse
Affiliation(s)
- Jan Powers
- St. Vincent Hospital, 2001 West 86th Street, Indianapolis, IN 46260, USA.
| | - Karen Samaan
- St. Vincent Hospital, 2001 West 86th Street, Indianapolis, IN 46260, USA
| |
Collapse
|
11
|
Lefrant JY, Hurel D, Cano N, Ichai C, Preiser JC, Tamion F. Nutrition artificielle en réanimation. NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
12
|
|
13
|
Lefrant JY, Hurel D, Cano NJ, Ichai C, Preiser JC, Tamion F. [Guidelines for nutrition support in critically ill patient]. ACTA ACUST UNITED AC 2014; 33:202-18. [PMID: 24565944 DOI: 10.1016/j.annfar.2014.01.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J-Y Lefrant
- Services des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hurel
- Service de réanimation médico-chirurgicale, centre hospitalier François-Quesnay, 2, boulevard Sully, 78201 Mantes-la-Jolie cedex, France
| | - N J Cano
- Service de nutrition, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand cedex, France; Unité de nutrition humaine, Clermont université, université d'Auvergne, BP 10448, 63000 Clermont-Ferrand, France; Inra, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - C Ichai
- Service de réanimation médico-chirurgicale, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06006 Nice cedex 1, France
| | - J-C Preiser
- Service des soins intensifs, hôpital universitaire Erasme, 808, route de Lennik, 1070 Bruxelles, Belgique
| | - F Tamion
- Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76081 Rouen cedex, France
| |
Collapse
|
14
|
Veldsman L. Saspen Case Study: Intra-abdominal hypertension. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2014. [DOI: 10.1080/16070658.2014.11734491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
15
|
Hoffer LJ, Bistrian BR. Why critically ill patients are protein deprived. JPEN J Parenter Enteral Nutr 2013; 37:300-9. [PMID: 23459750 DOI: 10.1177/0148607113478192] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore.
Collapse
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
| | | |
Collapse
|
16
|
Hoffer LJ, Bistrian BR. Appropriate protein provision in critical illness: a systematic and narrative review. Am J Clin Nutr 2012; 96:591-600. [PMID: 22811443 DOI: 10.3945/ajcn.111.032078] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Widely varying recommendations have been published with regard to the appropriate amount of protein or amino acids to provide in critical illness. OBJECTIVE We carried out a systematic review of clinical trials that compared the metabolic or clinical effects of different protein intakes in adult critical illness and comprehensively reviewed all of the available evidence pertinent to the safe upper limit of protein provision in this setting. DESIGN MEDLINE was searched for clinical trials published in English between 1948 and 2012 that provided original data comparing the effects of different levels of protein intake on clinically relevant outcomes and evidence pertinent to the safe upper limit of protein provision to critically ill adults. RESULTS The limited amount and poor quality of the evidence preclude conclusions or clinical recommendations but strongly suggest that 2.0-2.5 g protein substrate · kg normal body weight⁻¹ · d⁻¹ is safe and could be optimum for most critically ill patients. At the present time, most critically ill adults receive less than half of the most common current recommendation, 1.5 g protein · kg⁻¹ · d⁻¹, for the first week or longer of their stay in an intensive care unit. CONCLUSION There is an urgent need for well-designed clinical trials to identify the appropriate level of protein provision in critical illness.
Collapse
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.
| | | |
Collapse
|
17
|
The BASA-ROT table: An arithmetic–hypothetical concept for easy BMI-, age-, and sex-adjusted bedside estimation of energy expenditure. Nutrition 2012; 28:773-8. [DOI: 10.1016/j.nut.2011.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 11/17/2011] [Accepted: 11/17/2011] [Indexed: 12/25/2022]
|
18
|
de Aguilar-Nascimento JE, Bicudo-Salomao A, Portari-Filho PE. Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions. Nutrition 2012; 28:840-3. [PMID: 22554957 DOI: 10.1016/j.nut.2012.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 12/05/2011] [Accepted: 01/20/2012] [Indexed: 11/28/2022]
Abstract
The early provision of nutrients as part of specialized therapy for critically ill patients admitted for critical medical and surgical conditions is recommended by various international guidelines. Enteral nutrition is the first option and should be initiated 24-48 h after admission to an intensive care unit. Even after gastrointestinal anastomosis, early oral or enteral feeding is not only safe but also associated with enhanced recovery and fewer complications. Recent studies showed that the use of an enteral diet or parenteral nutrition that contains immune nutrients enhances the recovery of critically ill patients. Although the precise caloric target remains controversial, the general consensus advocates the avoidance of prolonged hypocaloric or hypercaloric feeding. However, there is still debate about the timing of the initiation of parenteral nutrition when enteral nutrition either is impossible or does not meet the nutritional goals. Although controversy remains, two recent studies showed that when enteral feeding is not feasible the early initiation of parenteral nutrition was not associated with palpable benefit.
Collapse
|
19
|
Abstract
Background Children undergoing hematopoietic stem cell transplantation (HSCT) typically receive parenteral nutrition (PN) due to gastrointestinal toxicities. Accurate determination of resting energy expenditure (REE) may facilitate optimal energy provision and help avoid unintended overfeeding or underfeeding. Methods In a multicenter, prospective cohort study of children undergoing allogeneic HSCT, REE was measured by indirect calorimetry at baseline and twice weekly until 30 days after transplantation. Change in percent predicted REE over time from admission was analyzed using repeated measures regression analysis. Results Twenty-six children (14 females) with a mean (SD) age of 14.9 (4.2) years who underwent an HLA-matched sibling or unrelated donor transplantation were enrolled. Mean (SD) percent predicted REE at baseline was 92.4 (15.2). Baseline REE was highly correlated with lean body mass measured by DXA (r=0.78, p<.0001). REE decreased significantly over time, following a quadratic curve to a nadir of 79% predicted at 14 days post transplantation (p <0.001) and returned to near baseline by day 30. Conclusions Children undergoing HSCT exhibit a significant reduction in REE in the early weeks after transplantation, a phenomenon that places them at risk for overfeeding. Serial measurements of REE or reductions in energy intake should be considered when PN is the primary mode of nutrition.
Collapse
|