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Bernardes S, Stello BB, Milanez DSJ, Razzera EL, Silva FM. Refeeding syndrome risk at ICU admission is an independent predictor of ICU readmission but it is not associated with mortality or length of stay in critically ill patients. Intensive Crit Care Nurs 2024; 85:103716. [PMID: 38834440 DOI: 10.1016/j.iccn.2024.103716] [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] [Received: 03/16/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVES This study evaluated the association between refeeding syndrome (RFS) risk and intensive care unit (ICU)/in-hospital mortality and length of stay (LOS) and ICU readmission in critically ill patients. METHODS This secondary analysis of a cohort study included patients aged ≥ 18 years admitted at ICU 24 h before data collection. We evaluated RFS risk based on the National Institute for Health and Clinical Excellence (NICE), stratifying it into four categories (no, low, high, and very-high risk). SETTING Five adult ICUs in Brazil. MAIN OUTCOME MEASURES ICU/in-hospital mortality and LOS and ICU readmission data were obtained from electronic medical records analysis, following patients until discharge (alive or not). RESULTS The study involved 447 patients, categorized into no (19.2 %), low (28.6 %), high (48.8 %), and very-high (3.4 %) RFS risk groups. No significant differences emerged between the two groups (at RFS risk and no RFS risk) regarding the ICU death ratio (34.3 % versus 23.4 %) and LOS (5 versus 4 days), respectively. In contrast, patients at RFS risk experienced higher in-hospital mortality rates (34.3 % versus 23.4 %) prolonged hospital LOS (21 days versus 17 days), and increased ICU readmission rates (15 % versus 8.4 %) than patients without RFS risk. After adjusting for age and Sequential Organ Failure Assessment (SOFA) Score, we found no association between RFS risk and increased mortality in the ICU or hospital. Also, there was no significant association between RFS risk and prolonged LOS in the ICU or hospital setting. However, patients identified as at risk of RFS showed nearly double the odds of ICU readmission (Odds ratio, 1.90; 95 % CI 1.02-3.43). CONCLUSIONS This study found no significant association between RFS risk and increased mortality in both the ICU and hospital settings, nor was there a significant association with prolonged LOS in the ICU or hospital among critically ill patients. However, patients at risk of RFS exhibited nearly double the odds of ICU readmission. IMPLICATIONS FOR CLINICAL PRACTICE Our findings may contribute to understanding risks associated with ICU readmissions, highlighting the complexity of discharge decision-making through comprehensive assessments.
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Affiliation(s)
- Simone Bernardes
- Nutrition Science Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Bruna Barbosa Stello
- Nutrition Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Danielle Silla Jobim Milanez
- Nutrition Science Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Elisa Loch Razzera
- Nutrition Science Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Nutrition Science Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.
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Wang L, Zhong X, Yang H, Yang J, Zhang Y, Zou X, Wang L, Zhang Z, Jin X, Kang Y, Wu Q. When can we start early enteral nutrition safely in patients with shock on vasopressors? Clin Nutr ESPEN 2024; 61:28-36. [PMID: 38777444 DOI: 10.1016/j.clnesp.2024.03.007] [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] [Received: 09/23/2023] [Revised: 02/17/2024] [Accepted: 03/03/2024] [Indexed: 05/25/2024]
Abstract
Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.
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Affiliation(s)
- Luping Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xia Zou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Lijie Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Shen Y, Qiu B, Ge Q, Hu L, Cong Z, Wu Y. Effect of early enteral nutrition on short-term outcomes and survival in patients in the cardiothoracic intensive care unit: An inverse probability weighted retrospective study. Nutrition 2024; 119:112328. [PMID: 38237353 DOI: 10.1016/j.nut.2023.112328] [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] [Received: 09/28/2023] [Revised: 11/15/2023] [Accepted: 12/09/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The merits of early enteral nutrition (EEN) in patients in the cardiothoracic intensive care unit (CTICU) remain unclear. This retrospective study aimed to address this issue. METHODS We analyzed data from the MIMIC IV v2.0 database, including patients with a CTICU stay of ≥4 d. Patients were divided into early and delayed enteral nutrition (EN) groups. Differences in baseline data were corrected using an inverse probability weighting (IPW) approach. Generalized linear models (GLMs) were used to compare trends over time between groups, and survival effects were evaluated with weighted logistic and Cox regression, supplemented by weighted Kaplan-Meier curves. Subgroup analysis facilitated the exploration of potential interactions. RESULTS The study included 720 CTICU patients. Following IPW, all baseline variables were balanced. EEN led to shorter hospital and CTICU stays, lower incidence of respiratory and blood infections, and reduced total insulin usage in the first week of CTICU admission, albeit with an increased total gastric residual volume. Mortality risk between the groups did not significantly differ at 28 d or at 1 y. Excessive early energy and protein intake elevated the risk of 28-d mortality, but the relationship may not be linear. Overweight patients or those with fewer comorbidities had a higher mortality risk with EEN. CONCLUSIONS EEN may improve short-term outcomes in CTICU patients without a clear survival benefit. Early high caloric and protein intake could lead to adverse outcomes, suggesting a careful evaluation for initiating EN in specific patients.
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Affiliation(s)
- Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China; Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Bingmei Qiu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jiangsu, China
| | - Qiyue Ge
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China
| | - Liwen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Zhuangzhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Yuheng Wu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China.
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Bagley K, Schuller JG. Mesenteric ischemia in the acute care setting. Nursing 2024; 54:48-55. [PMID: 38271132 DOI: 10.1097/01.nurse.0000998028.77929.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
ABSTRACT Mesenteric ischemia is a group of disorders requiring prompt identification, supportive care, and treatment. Chronic mesenteric ischemia can develop into acute mesenteric ischemia, which has high mortality. Acute mesenteric ischemia can be occlusive (caused by arterial embolism, arterial thrombosis, or mesenteric venous thrombosis) or nonocclusive, with treatment depending on the underlying cause.
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Saleh NY, Aboelghar HM, Abdelaty NB, Garib MI, Mahmoud AA. Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial. Clin Exp Pediatr 2023; 66:403-411. [PMID: 37321580 PMCID: PMC10475857 DOI: 10.3345/cep.2023.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/27/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial. PURPOSE To identify the optimal timing of PN initiation in critically ill children. METHODS This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes. RESULTS Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018). CONCLUSION Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.
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Affiliation(s)
- Nagwan Y. Saleh
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Hesham M. Aboelghar
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Nehad B. Abdelaty
- Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Mohamed I. Garib
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Asmaa A. Mahmoud
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
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Qi F, Huang G, Li H, Zhao X, Liu J. Correlation analysis of norepinephrine dose on enteral nutrition tolerance and prognosis in patients with septic shock. BMC Infect Dis 2023; 23:386. [PMID: 37291494 DOI: 10.1186/s12879-023-08366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/01/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND To explore correlation between the dose of norepinephrine and the timing of starting enteral nutrition in septic shock (SS) patients. METHODS Totally 150 SS patients treated with enteral nutrition (EN) in Shiyan People's Hospital from Dece20 to July 2022 were included in this retrospective analysis. Patients were divided into tolerance group (n = 97) and intolerance group (n = 53) according to whether EN was tolerated or not. The study indexes include baseline characteristics [gender, age, weight, body mass index (BMI), scores of acute physiology and chronic health evaluation II system (APACHE II), comorbidity, time in-hospital, prognosis], clinical indexes [mean arterial pressure (MAP), time of mechanical ventilation (MV), norepinephrine dose at the time of starting EN, using of sedative drug, gastrointestinal motility drugs and cardiotonic drugs], EN indexes (timing of starting EN, speed of EN infusion, calorie of EN per day, EN target percent), and gastrointestinal intolerance index [residual gastric volume > 250 ml, vomiting, aspiration, gastrointestinal bleeding, blood lactic acid (BLA)]. Student-t test and Mann-Whitney test were used for test of measurement data. Chi-square test and fisher exact test were used for comparison of categorical data. RESULTS There were 51 (52.58%) male and 46 (47.42%) female patients with a median age of 66.4 ± 12.8 years old in tolerance group. There were 29 (54.72%) male and 24 (45.28%) female patients with a median age 67.3 ± 12.5 years old in intolerance group. The weight and BMI were significantly higher in intolerance group than those of tolerance group (both P < 0.001). There was no significant difference of comorbidity rate between two groups (all P > 0.05). Before the overlapping time of EN and norepinephrine, there were significantly more patients receiving gastrointestinal motility drugs in intolerance group compared with tolerance group (58.49% vs. 20.62%, P < 0.001). Patients in tolerance group had significantly less residual volume in gastric than that of intolerance group (188.00 ± 52.32 vs. 247.83 ± 34.95, P < 0.001). The rate of residual volume in gastric > 250ml (9.28% vs. 37.74%, P < 0.001), vomiting (15.46% vs. 35.85%, P = 0.004) and aspiration(16.49% vs. 33.96%, P = 0.018) were significantly lower in tolerance group than those of intolerance group. The BLA in tolerance group was significantly lower than that of intolerance group (1.84 ± 0.63 vs. 2.90 ± 1.5 3mmol/L,P < 0.001). There were significantly more patients with increased BLA (75.47% vs. 30.93%, P < 0.001) and > 2mmol BLA rising (43.40% vs. 8.25%, P < 0.001) in intolerance group than those of tolerance group. Patients in tolerance group had significantly lower time of starting EN (40.97 ± 9.53 vs. 49.85 ± 11.61 h, P < 0.001), dose of NE(0.23 ± 0.07 vs. 0.28 ± 0.10 ug/kg/min, P = 0.049), mortality in hospital (18.56% vs. 49.06%, P < 0.001) and mortality in ICU (16.49% vs. 37.74%, P < 0.001) compared with intolerance group. The EN target percent (92.78% vs. 56.60%, P < 0.001) and calorie of EN during overlapping period (20.22 ± 5.99 vs. 16.21 ± 2.52 kcal/kg/day, P < 0.001) in tolerance group were significantly higher than those of intolerance group. CONCLUSIONS SS patients should be comprehensively evaluated according to their condition. Obese patients are more prone to EN intolerance, and those who can tolerate EN should be implemented as soon as possible. The use dose of NE is significantly related to EN tolerance. When the use dose is low, EN tolerance is greater.
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Affiliation(s)
- Fan Qi
- Jinzhou Medical University, Jinzhou, China
| | - Guangqing Huang
- Emergency and Critical Care Center, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Hunian Li
- Emergency and Critical Care Center, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Xu Zhao
- Emergency and Critical Care Center, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China
| | - Jie Liu
- Emergency and Critical Care Center, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei, 442000, China.
- Maternal and Child Health Care Hospital Affiliated to Hubei University of Medicine, Shiyan, 442000, China.
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Jeong H, Kim JH, Choo YH, Kim M, Lee S, Ha EJ, Oh J. Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review. Korean J Neurotrauma 2023; 19:177-184. [PMID: 37431366 PMCID: PMC10329886 DOI: 10.13004/kjnt.2023.19.e31] [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: 06/02/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023] Open
Abstract
Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.
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Affiliation(s)
- Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Bagley K, Schuller JG. Mesenteric ischemia in the acute care setting. Nurse Pract 2023; 48:17-25. [PMID: 37227311 DOI: 10.1097/01.npr.0000000000000053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
ABSTRACT Mesenteric ischemia is a group of disorders requiring prompt identification, supportive care, and treatment. Chronic mesenteric ischemia can develop into acute mesenteric ischemia, which has high mortality. Acute mesenteric ischemia can be occlusive (caused by arterial embolism, arterial thrombosis, or mesenteric venous thrombosis) or nonocclusive, with treatment depending on the underlying cause.
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Moliner-Calderón E, Verd S, Leiva A, Ginovart G, Moll-McCarthy P, Figueras-Aloy J. The role of human milk feeds on inotrope use in newborn infants with sepsis. Front Pediatr 2023; 11:1172799. [PMID: 37138570 PMCID: PMC10150957 DOI: 10.3389/fped.2023.1172799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/16/2023] [Indexed: 05/05/2023] Open
Abstract
Background Regarding neonatal hypotension, there is no certainty as to whether inotrope properties are beneficial or whether they may be harmful. However, given that the antioxidant content of human milk plays a compensatory role in neonatal sepsis and that human milk feeding has direct effects in modulating the cardiovascular function of sick neonates, this research hypothesized that human milk feeds might predict lower requirements of vasopressors in the management of neonatal septic shock. Method Between January 2002 and December 2017, all late preterm and full-term infants attending a neonatal intensive care unit, with clinical and laboratory findings of bacterial or viral sepsis, were identified in a retrospective study. During their first month of life, data on feeding type and early clinical characteristics were collected. A multivariable logistic regression model was constructed to determine the impact of human milk on the use of vasoactive drugs in septic newborns. Results 322 newborn infants were eligible to participate in this analysis. Exclusively formula-fed infants were more likely to be delivered via C-section, to have a lower birth weight and a lower 1-minute Apgar score than their counterparts. Human milk-fed newborns had 77% (adjusted OR = 0.231; 95% CI: 0.07-0.75) lower odds of receiving vasopressors than exclusively formula-fed newborns. Conclusion We report that any human milk feeding is associated with a decrease in the need for vasoactive medications in sepsis-affected newborns. This observation encourages us to undertake further research to determine whether human milk feeds mitigate the use of vasopressors in neonates with sepsis.
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Affiliation(s)
| | - Sergio Verd
- Pediatric Unit, La Vileta Surgery, Department of Primary Care, Palma de Mallorca, Spain
- Group of Cell Therapy and Tissue Engineering, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain
- Correspondence: Sergio Verd
| | - Alfonso Leiva
- Research Unit, Department of Primary Care, Palma de Mallorca, Spain
| | - Gemma Ginovart
- Neonatal Unit, Department of Paediatrics, Germans Trias I Pujol Hospital, Badalona, Spain
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Association of Vasopressors Dose Trajectories with Enteral Nutrition Tolerance in Patients with Shock: A Prospective Observational Study. Nutrients 2022; 14:nu14245393. [PMID: 36558552 PMCID: PMC9782535 DOI: 10.3390/nu14245393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Studies on the long-term patterns of using vasopressors in patients with shock and their correlations with the risk of feeding intolerance (FI) are limited. This study aimed to characterize the norepinephrine equivalent dose (NEQ) trajectories and explore its correlations with FI in patients with shock. (2) Methods: This study prospectively enrolled patients with shock, who received vasopressors from August 2020 to June 2022. The Growth Mixed Model (GMM) was used to traverse longitudinal NEQ data at six-hour intervals and identify the latent trajectories of NEQ use in these patients. Cox proportional hazards regression models were used to examine the correlations of NEQ trajectories with FI. (3) Results: This study included a total of 210 patients with shock recruited from August 2020 to June 2022. Four trajectories of NEQ dose were identified and characterized by low-dose stable NEQ (L-NEQ, n = 98), moderate-dose stable NEQ (M-NEQ, n = 74), high-dose stable NEQ (H-NEQ, n = 21), and rapidly rising NEQ (R-NEQ, n = 17), with NEQ doses of 0.2, 0.4, 0.4, and 0.5 µg/kg/min at enteral nutrition (EN) initiation, respectively. The incidences of FI were 37.76%, 67.57%, 80.95%, and 76.47% in the L-NEQ, M-NEQ, H-NEQ, and R-NEQ groups, respectively (p < 0.001). As compared to the L-NEQ group, the risk of FI occurrence increased in the M-NEQ, H-NEQ, and R-NEQ groups (all p < 0.05). (4) Conclusions: The risk of FI was significantly associated with NEQ trajectories. It might be appropriate to initiate EN when the NEQ dose is stabilized below 0.2 µg/kg/min in patients with shock.
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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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Nutrition in ICU Patients. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0041-1739526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Modir R, Hadhazy E, Teuteberg J, Hiesinger W, Tulu Z, Hill C. Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study. Nutr Clin Pract 2022; 37:677-697. [PMID: 35606342 DOI: 10.1002/ncp.10854] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. METHODS We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. RESULTS Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). CONCLUSION This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.
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Affiliation(s)
- Ranna Modir
- Clinical Nutrition, Advanced Heart Failure/Mechanical Circulatory Support/Heart Transplant, Stanford Healthcare, Stanford, California, USA
| | - Eric Hadhazy
- Critical Care Quality, Stanford Healthcare, Stanford, California, USA
| | - Jeffrey Teuteberg
- Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | - William Hiesinger
- Cardiothoracic Surgery - Adult Cardiac Surgery, Stanford University Medical center, Stanford, California
| | - Zeynep Tulu
- Solid Organ Transplant Quality, Stanford Healthcare, Stanford, California, USA
| | - Charles Hill
- Anesthesia - Cardiac, Stanford University Medical Center, Stanford, California, USA
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Dorken Gallastegi A, Gebran A, Gaitanidis A, Naar L, Hwabejire JO, Parks J, Lee J, Kaafarani HMA, Velmahos GC, Mendoza AE. Early versus late enteral nutrition in critically ill patients receiving vasopressor support. JPEN J Parenter Enteral Nutr 2021; 46:130-140. [PMID: 34599785 DOI: 10.1002/jpen.2266] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/14/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Outcomes of early enteral nutrition (EEN) in critically ill patients on vasoactive medications remain unclear. We aimed to compare in-hospital outcomes for EEN vs late EN (LEN) in mechanically ventilated patients receiving vasopressor support. METHODS This was a retrospective study using the national eICU Collaborative Research Database. Adult patients requiring vasopressor support and mechanical ventilation within 24 h of admission and for ≥2 days were included. Patients with an admission diagnosis that could constitute a contraindication for EEN (eg, gastrointestinal [GI] perforation, GI surgery) and patients with an intensive care unit (ICU) length of stay (LOS) <72 h were excluded. EEN and LEN were defined as tube feeding within 48 h and between 48 h and 1 week (nothing by mouth during the first 48 h) of admission, respectively. Propensity score matching was performed to derive two cohorts receiving EEN and LEN that were comparable for baseline patient characteristics. RESULTS Among 1701 patients who met the inclusion criteria (EEN: 1001, LEN: 700), 1148 were included in propensity score-matched cohorts (EEN: 574, LEN: 574). Median time to EN was 29 vs 79 h from admission in the EEN and LEN groups, respectively. There was no significant difference in mortality or hospital LOS between the two nutrition strategies. EEN was associated with shorter ICU LOS, lower need for renal replacement therapy, and lower incidence of electrolyte abnormalities. CONCLUSION This study showed no difference in 28-day mortality between EEN and LEN in critically ill patients receiving vasopressor support.
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Affiliation(s)
- Ander Dorken Gallastegi
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Gebran
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Apostolos Gaitanidis
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leon Naar
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Parks
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April E Mendoza
- Division of Trauma Emergency Surgery Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Ruiz NC, Kamel AY, Shoulders BR, Rosenthal MD, Murray-Casanova IM, Brakenridge SC, Moore FA. Nonocclusive mesenteric ischemia: A rare but lethal complication of enteral nutrition in critically ill patients. Nutr Clin Pract 2021; 37:715-726. [PMID: 34462980 DOI: 10.1002/ncp.10761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism guidelines recognize that critically ill patients receiving stable, low doses of vasopressors have experienced the advantages of early initiation of enteral nutrition (EN). However, clinical questions remained unanswered including vasopressor combinations associated with complications, the advent of other therapies during hypotensive states, as well as the volume and content of EN that might contribute to the development of a nonocclusive mesenteric ischemia (NOMI). PRESENTATION A 68-year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease with two-vessel bypass grafting, and peripheral vascular disease underwent subtotal excision of an infected right axillofemoral-femoral bypass graft. Postoperatively, EN was held because of hemodynamic instability and postsurgical complications. A fiber-free, high-protein, and low-residue formula was started at 10 ml/h while the patient was receiving stable doses of midodrine, norepinephrine, and vasopressin. Despite advancement of tube-feed rates to goal, nasogastric output never exceeded 300 ml. Computerized tomography of the abdomen showed diffuse bowel distention with pneumatosis, concerning for bowel ischemia. No surgical interventions were pursued, and the patient died. CONCLUSIONS Our patient developed NOMI postoperatively while receiving EN. Further studies addressing EN route, trophic vs full EN, recommended formula, the safety of vasoactive agents, the addition of fiber to EN, and continuous venovenous hemodiafiltration in relation to NOMI are needed, as there continues to be clinical controversy regarding these topics.
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Affiliation(s)
- Nicole C Ruiz
- Department of Internal Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Amir Y Kamel
- Department of Pharmacy, Nutrition Support/Critical Care Clinical Pharmacy Specialist, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Bethany R Shoulders
- Clinical Pharmacy Specialist, Surgical/Trauma ICU, College of Pharmacy, University of Florida and UF Health Shands Hospital, Gainesville, Florida, USA
| | - Martin D Rosenthal
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Irina M Murray-Casanova
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Scott C Brakenridge
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Frederick A Moore
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, College of Medicine, University of Florida, Gainesville, Florida, USA
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16
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Necrosis intestinal asociada a la nutrición enteral por yeyunostomía. ENDOCRINOL DIAB NUTR 2021; 68:74-75. [DOI: 10.1016/j.endinu.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/05/2020] [Accepted: 01/11/2020] [Indexed: 11/22/2022]
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17
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Loudet CI, Marchena MC, Tumino LI, Cabana ML, Capurro G, Astegiano P, Velásquez MA, Casanova M, Rodríguez Bugueiro MJ, Roth MC, Roda G, Gimbernat R, Balmaceda YDV, Okurzaty P, Perman MI, González AL, Reina R, Estenssoro E. Prognostic capability of the Maximum Acute Gastrointestinal Injury Score and of caloric intake in patients requiring vasopressors: A multicenter prospective cohort study. J Crit Care 2020; 58:41-47. [PMID: 32335494 DOI: 10.1016/j.jcrc.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Our main objective was to use the Maximum Acute Gastrointestinal Injury Score (AGImax) to evaluate the prognostic capability of gastrointestinal dysfunction (GID), on hospital mortality in patients on mechanical ventilation (MV) requiring vasopressors. A secondary goal was to analyze the relationship between AGImax and vasopressor dosage with increasing caloric intake. MATERIALS AND METHODS Prospective multicenter cohort study in ten ICUs across Argentina. Consecutive adult patients on MV, requiring vasopressors and receiving enteral nutrition (EN) were included. AGImax was identified (I-IV) using a modified AGI score. Comparisons of clinical and outcome variables were performed in 3 predetermined EN-groups: <10 kcal/kg/d, ≥10 to <20 kcal/kg/d, or ≥ 20 kcal/kg/d. RESULTS A total of 494 patients met all inclusion criteria. Forty-four percent of patients had severe AGImax and 17% received <10 kcal/kg/day, indicating more severity and higher mortality. Notable independent predictors of mortality were AGImax, vasopressors, and caloric intake. PN was the only factor which had an inverse relationship to mortality. CONCLUSIONS In this population, patients with AGImax III-IV were significantly associated with lower caloric intake and greater hospital mortality, highlighting the importance of AGI as a prognostic tool. As PN was linked with lower mortality, it could be an option to explore in further studies.
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Affiliation(s)
- Cecilia I Loudet
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina; Cátedra de Farmacología Aplicada, Universidad Nacional de La Plata, Argentina.
| | - María C Marchena
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Leandro I Tumino
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - María L Cabana
- Servicio de Terapia Intensiva, Hospital Pablo Soria, Jujuy, Argentina
| | - Gabriela Capurro
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos Dr. Oscar Alende, Mar del Plata, Argentina
| | - Paulina Astegiano
- Servicio de Terapia Intensiva, Hospital José María Cullen, Santa Fe, Argentina
| | - Mariela A Velásquez
- Unidad de Terapia Intensiva, Sanatorio Nuestra Señora del Rosario, Jujuy, Argentina
| | - Matías Casanova
- Servicio de Terapia Intensiva, Hospital El Cruce, Florencio Varela, Argentina
| | | | - María C Roth
- Servicio de Terapia Intensiva, Hospital San Juan de Dios, La Plata, Argentina
| | - Gisela Roda
- Servicio de Terapia Intensiva, Hospital Municipal Eva Perón, Merlo, Argentina
| | - Rolando Gimbernat
- Unidad de Terapia Intensiva, Centro de Cuidados Intensivos, San Juan, Argentina
| | | | - Patricia Okurzaty
- Unidad de Terapia Intensiva, Casa Hospital San Juan de Dios, Ramos Mejía, Argentina
| | - Mario I Perman
- Asociación Argentina de Nutrición Enteral y Parenteral (AANEP), Argentina
| | - Ana L González
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Rosa Reina
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
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Vasopressors and Nutrition Therapy: Safe Dose for the Outset of Enteral Nutrition? Crit Care Res Pract 2020; 2020:1095693. [PMID: 32104602 PMCID: PMC7035530 DOI: 10.1155/2020/1095693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 12/24/2022] Open
Abstract
Background and Aims Patients with hemodynamic instability need to receive intensive treatment as fluid replacement and vasoactive drugs. In the meantime, it is supposed to initiate nutritional therapy within 24 to 48 hours after admission to the intensive care unit (ICU), as an essential part of patient's intensive care and better outcomes. However, there are many controversies tangential to the prescription of enteral nutrition (EN) concomitant to the use of vasopressor and its doses. In this way, the present study aimed to identify what the literature presents of evidence to guide the clinical practice concerning the safe dose of vasopressors for the initiation of nutritional therapy in critically ill patients. Methods This review was carried out in PubMed, ProQuest, Web of Science, and Medline databases. The descriptors were used to perform the search strategy: Critical Care, Intensive Care Units, Vasoconstrictor Agents, and Enteral Nutrition. Inclusion criteria were patients of both genders, over 18 years of age, using vasoactive drugs, with the possibility of receiving EN therapy, and articles written in English, Portuguese, and Spanish. In addition, exclusion criteria were case reports, non-papers, and repeated papers. Results 10 articles met our inclusion criteria. Conclusion It was observed that there are many controversies about the supply of EN in critically ill patients using vasopressor, especially about the safe dose, and it was not possible to identify a cutoff value for the beginning therapy. Despite the drug doses, clinical signs are still the most important parameters in the evaluation of EN tolerance.
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19
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Savio RD, Parasuraman R, Lovesly D, Shankar B, Ranganathan L, Ramakrishnan N, Venkataraman R. Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position. J Intensive Care Soc 2020; 22:41-46. [PMID: 33643431 DOI: 10.1177/1751143719900100] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Aim To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS). Methods Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients' demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded. Results Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position. Conclusion In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.
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20
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Rao Y, Saxena R, Midha T, Rao N, Saxena V. Clinical outcome of enteral nutrition versus IV fluids in newborns on inotropes: A randomized study. J Clin Neonatol 2020. [DOI: 10.4103/jcn.jcn_48_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Bal AM, McGill M. Rapid species identification of Candida directly from blood culture broths by Sepsityper-MALDI-TOF mass spectrometry: impact on antifungal therapy. J R Coll Physicians Edinb 2019; 48:114-119. [PMID: 29992199 DOI: 10.4997/jrcpe.2018.203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rapid identification of Candida species facilitates pathogen-directed therapy with either fluconazole or an echinocandin. METHOD We applied Sepsityper matrix-assisted laser desorption ionisation time of flight mass spectrometry (MALDI-TOF-MS) technology on positive blood culture broths for rapid species identification. RESULTS Of the 74 patients with candidaemia, 25 had the species identified on the day of the positive blood culture directly from the broth (rapid identification group) while the remaining 49 had the species identified from culture (conventional identification group). Three (13.6%) out of 22 treated patients in the rapid identification group received echinocandin compared to 20/45 (44.4%) in the conventional identification group. The appropriateness of therapy was 90.9% in the rapid identification group and 62.2% in the conventional identification group (p = 0.01). Cost savings were more than £10,000 in the first three days of treatment. CONCLUSION Sepsityper-MALDI-TOF-MS is a useful tool in supporting antifungal stewardship programmes.
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Affiliation(s)
- A M Bal
- Department of Microbiology, University Hospital, Crosshouse, Kilmarnock KA2 0BE, UK,
| | - M McGill
- Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK
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Hunt MF, Pierre AS, Zhou X, Lui C, Lo BD, Brown PM, Whitman GJ, Choi CW. Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study. J Surg Res 2019; 244:257-264. [PMID: 31302323 DOI: 10.1016/j.jss.2019.06.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/25/2019] [Accepted: 06/14/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients. MATERIALS AND METHODS We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications. RESULTS ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications. CONCLUSIONS -ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.
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Affiliation(s)
- Megan F Hunt
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Xun Zhou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cecillia Lui
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian D Lo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patricia M Brown
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn J Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun W Choi
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Zonies D, Codner P, Park P, Martin ND, Lissauer M, Evans S, Cocanour C, Brasel K. AAST Critical Care Committee clinical consensus: ECMO, nutrition. Trauma Surg Acute Care Open 2019; 4:e000304. [PMID: 31058243 PMCID: PMC6461143 DOI: 10.1136/tsaco-2019-000304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 01/15/2023] Open
Abstract
The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.
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Affiliation(s)
- David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Panna Codner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pauline Park
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Lissauer
- Department of Surgery, Rutgers-Robert Wood Johnson, Rutgers, New Jersey, USA
| | - Susan Evans
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Christine Cocanour
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Karen Brasel
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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McCann C, Cullis PS, McCabe AJ, Munro FD. Major complications of jejunal feeding in children. J Pediatr Surg 2019; 54:258-262. [PMID: 30528177 DOI: 10.1016/j.jpedsurg.2018.10.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
AIM OF THE STUDY The aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients. METHODS All patients undergoing jejunal feeding between 1/2008 and 1/2018 at a pediatric surgical unit were identified retrospectively. Data sought from records included demographics, comorbidities, indications, feeding strategies, adverse events, and follow-up. Major surgical complications were defined by Clavien-Dindo grade ≥ IIIb and involving the GI tract (excluding changes of jejunal tube). MAIN RESULTS 197 patients were identified (110 female). Median age (IQR) at initiation of jejunal feeding months was 5.6 (6-164) months. 122 were neurologically impaired. The most frequent indications were: GERD/gastroparesis (n = 114), prophylaxis/treatment of Superior Mesenteric Artery (SMA) syndrome (N.B. our center is a national spinal deformity unit) (n = 47), congenital anomalies of aerodigestive anatomy (n = 17), and malignancy (n = 7). 125 patients were managed with nasojejunal feeding alone: gastrojejunal tube (n = 51) and via Roux-en-Y jejunostomy (n = 21). There were 14 significant gastrointestinal complications (n = 11 grade > IIIb) identified among 12 patients, of whom 8 required bowel resections, and 2 died as a result: nonmechanical bowel ischemia (n = 7), intussusception (n = 4), and volvulus (n = 3). CONCLUSION This series highlights the major complications of jejunal feeding, including a significant yet underreported risk of gut compromise. Patients undergoing jejunal feeding had a 6.1% risk of developing major surgical complications (of note, 3.6% developed bowel ischemia of unknown etiology). Susceptible children were comorbid, fragile, and neurologically impaired. These findings should influence parental discussions and informed consent before embarking upon jejunal feeding. LEVEL OF EVIDENCE Level IV prognosis study.
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Affiliation(s)
- Conor McCann
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Amanda J McCabe
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Fraser D Munro
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK.
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26
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Joo WJ, Ide K, Kawasaki Y, Takeda C, Seki T, Usui T, Kawakami K. Effectiveness and safety of early enteral nutrition for patients who received targeted temperature management after out-of-hospital cardiac arrest. Resuscitation 2019; 135:191-196. [PMID: 30648550 DOI: 10.1016/j.resuscitation.2019.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/15/2018] [Accepted: 01/03/2019] [Indexed: 01/15/2023]
Abstract
AIM Early enteral nutrition (EN) is recommended for critically ill patients; however, few reports have examined early EN for patients who received targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). We investigated the effectiveness and safety of early EN for patients who received TTM after OHCA. METHODS We used a nationwide Japanese administrative database to identify OHCA patients who received TTM from April 2008 to March 2017. The primary outcome was 30-day mortality; secondary outcomes were incidences of all-cause infection, pneumonia, and intestinal ischemia. RESULTS Of the 1932 OHCA patients who received TTM, 1682 met the inclusion criteria. Of these, 294 received early EN within 2 days from the initiation of TTM and 266 propensity-score matched pairs were generated. Cox regression analyses revealed no significant difference in 30-day mortality between groups (hazard ratio (HR): 0.90; 95% confidence interval (95% CI): 0.65-1.25). There was no significant difference in the incidence of all-cause infection (odds ratio (OR): 0.98; 95% CI: 0.66-1.46) or pneumonia (OR: 1.02; 95% CI: 0.68-1.55). Subgroup analyses of patients with a low body mass index (BMI; kg/m2) (< 18.5) revealed a significant decrease of 30-day mortality in the early EN group (HR: 0.30; 95% CI: 0.092-0.97) but no significant difference among patients with a BMI ≥ 18.5 (HR: 1.01; 95% CI: 0.72-1.43). CONCLUSION Among patients who received TTM after OHCA, there was no significant association between early EN and 30-day mortality; however, early EN could be beneficial for patients with a low BMI.
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Affiliation(s)
- Woo Jin Joo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto-city, Japan
| | - Kazuki Ide
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto-city, Japan; Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-city, Japan
| | - Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto-city, Japan; Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto-city, Japan
| | - Tomoko Usui
- Division of Nephrology and Endocrinology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshidakonoecho, Sakyo-ku, Kyoto-city, Japan; Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, Japan.
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27
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Mahmood S, Hoffman L, Ali IA, Zhao YD, Chen A, Allen K. Smart Phone/Device Application to Improve Delivery of Enteral Nutrition in Adult Patients Admitted to the Medical Intensive Care Unit. Nutr Metab Insights 2019; 12:1178638818820299. [PMID: 30643420 PMCID: PMC6322101 DOI: 10.1177/1178638818820299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/21/2018] [Indexed: 01/01/2023] Open
Abstract
Background Resident physicians are frequently uncomfortable ordering enteral nutrition (EN) and are unaware of the variety of formulas and supplements available for different disease processes. Many depend on a clinical dietician to assist with recommending EN formulas and patient energy requirements that may not be readily available on patient admission. This creates a barrier to early initiation of EN and non-compliance with Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition clinical guidelines. Objective Internal medicine resident physicians were provided an iPod with a smart phone/device application (EN application) to assist them in choosing EN formulas for patients during their intensive care unit (ICU) rotation. The primary outcome was improved initiation of EN within 24 hours of admission. Secondary outcomes included the following: time to initiate EN, goal calories reached, infections rates, length of stay, mortality, and concordance with clinical guidelines. Design The study is a quasi-experimental design to improve delivery of EN at an academic medical center in the medical ICU. Data were collected from a retrospective chart review to evaluate the impact of an EN application to assist resident physicians when ordering EN. Results Use of the EN application reduced the percent of patients with delayed initiation of EN from 61.2% prior to 37.5% (P < .01). The mean time to initiate EN also improved 44.5 vs 31.9 hours (P < .01). Patients were also more likely to achieve their daily caloric goal (P < .01). Conclusion The use of an EN application to assist internal medicine residents when ordering EN reduced delays in initiation of EN and improved overall delivery of EN to medical ICU patients.
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Affiliation(s)
- Sultan Mahmood
- Section of Gastroenterology, Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Leah Hoffman
- Department of Nutrition Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ijlal Akbar Ali
- Internal Medicine Residency Program, Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Yan D Zhao
- Department of Biostatistics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Allshine Chen
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Karen Allen
- Department of Pediatrics, the University of Oklahoma Health Sciences Center.,Pulmonary Section, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA.,College of Medicine, The University of Oklahoma, Oklahoma City, OK, USA
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Al-Diery H, Phillips A, Evennett N, Pandanaboyana S, Gilham M, Windsor JA. The Pathogenesis of Nonocclusive Mesenteric Ischemia: Implications for Research and Clinical Practice. J Intensive Care Med 2018; 34:771-781. [PMID: 30037271 DOI: 10.1177/0885066618788827] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nonocclusive mesenteric ischemia (NOMI) is a condition that can encompass ischemia, inflammation, and infarction of the intestinal wall. In contrast to most patients with acute mesenteric ischemia, NOMI is distinguished by patent arteries and veins. The clinical presentation of NOMI is often insidious and nonspecific, resulting in a delayed diagnosis. Patients most at risk are those with severe acute and critical disease, including major surgery and trauma. Nonocclusive mesenteric ischemia is part of a spectrum, from mild, asymptomatic, and an unexpected finding on CT scanning, through to those exhibiting abdominal distension and peritonitis. Severe NOMI is associated with a significant mortality rate. This review of NOMI pathophysiology was conducted to document current concepts and evidence, to examine the implications for diagnosis and treatment, and to identify gaps in knowledge that might direct future research. The key pathologic mechanisms involved in the genesis of NOMI represent an exaggerated normal physiological response to maintain perfusion of vital organs at the expense of mesenteric perfusion. A supply-demand mismatch develops in the intestine due to the development of persistent mesenteric vasoconstriction resulting in reduced blood flow and oxygen delivery to the intestine, particularly to the vulnerable superficial mucosa. This mismatch can be exacerbated by raised intra-abdominal pressure, enteral nutrition, and the use of certain vasoactive drugs, ultimately resulting in the development of intestinal ischemia. Strategies for prevention, early detection, and treatment are urgently needed.
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Affiliation(s)
- Hussam Al-Diery
- 1 Faculty of Medical and Health Sciences, Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Anthony Phillips
- 1 Faculty of Medical and Health Sciences, Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.,2 Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Nicholas Evennett
- 3 HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- 1 Faculty of Medical and Health Sciences, Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.,3 HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Michael Gilham
- 4 Cardiovascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - John A Windsor
- 1 Faculty of Medical and Health Sciences, Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.,2 Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand.,3 HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand.,5 Surgical Centre for Outcomes Research and Evaluation, Department of Surgery, University of Auckland, Auckland, New Zealand
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29
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Smyth J, Mullen CC, Jack L, Collier A, Bal AM. Diabetes, malignancy and age as predictors of Candida glabrata bloodstream infection: A re-evaluation of the risk factors. J Mycol Med 2018; 28:547-550. [PMID: 29803698 DOI: 10.1016/j.mycmed.2018.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 05/07/2018] [Accepted: 05/14/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Echinocandins and azoles are widely used in the treatment of candidaemia. Guidelines of the Infectious Diseases Society of America recommend commencing treatment with an echinocandin in candidaemic patients with risk factors for Candida glabrata i.e. patients who are elderly, or who have diabetes or malignancy, or those with recent prescription of azoles. We attempted to validate whether age, diabetes and malignancy are associated with C. glabrata candidaemia. PATIENTS, MATERIALS AND METHODS Information in relation to demographics, patient associated risk factors, and laboratory parameters were collected from the casenotes and the laboratory information system. We then analysed the distribution of the risk factors (age, diabetes, and malignancy) in candidaemic patients with C. glabrata and patients with species other than C. glabrata (excluding Candida krusei). RESULTS Over a 42-month period (April 2011-September 2017), 124 patients had candidaemia. We analysed data for 119 patients of whom 33 (27.7%) had C. glabrata and the remaining 86 (72.2%) were infected with other species. Sixty-five patients were elderly (age≥65), 40 had some form of malignancy, 34 had diabetes, and 4 patients were prescribed azoles in the 30 days prior to candidaemia (many patients had multiple risk factors). Comparing patients with C. glabrata to patients infected with other species, we found no association with diabetes (39.3% vs. 24.4%, P=0.1), malignancy (36.3 vs. 32.5%, P=0.69), and age (54.5% vs. 54.6%, P=0.99). CONCLUSIONS Diabetes, malignancy and age are not reliable predictors of candidaemia due to C. glabrata.
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Affiliation(s)
- J Smyth
- Department of Medicine, University Hospital Ayr, NHS Ayrshire and Arran, Lister street, KA2 0BE Kilmarnock, United Kingdom
| | - C C Mullen
- Department of Medicine, University Hospital Ayr, NHS Ayrshire and Arran, Lister street, KA2 0BE Kilmarnock, United Kingdom
| | - L Jack
- Department of Anaesthesia, University Hospital Crosshouse, NHS Ayrshire and Arran, Lister street, KA2 0BE Kilmarnock, United Kingdom
| | - A Collier
- Department of Medicine, University Hospital Ayr, NHS Ayrshire and Arran, Lister street, KA2 0BE Kilmarnock, United Kingdom
| | - A M Bal
- Department of Microbiology, University Hospital Crosshouse, NHS Ayrshire and Arran, Lister street, KA2 0BE Kilmarnock, United Kingdom.
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30
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Baǧci S, Keleş E, Girgin F, Yıldızdaş DR, Horoz ÖÖ, Yalındağ N, Tanyıldız M, Bayrakçi B, Kalkan G, Akyıldız BN, Köker A, Köroğlu T, Anıl AB, Zengin N, Dinleyici EÇ, Kıral E, Dursun O, Yavuz ST, Bartmann P, Müller A. Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey. J Paediatr Child Health 2018; 54:480-486. [PMID: 29278447 DOI: 10.1111/jpc.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 09/25/2017] [Accepted: 10/03/2017] [Indexed: 01/12/2023]
Abstract
AIM Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. METHODS We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). RESULTS Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. CONCLUSIONS There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children.
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Affiliation(s)
- Soyhan Baǧci
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Elif Keleş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Feyza Girgin
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Dinçer R Yıldızdaş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Özden Ö Horoz
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Nilüfer Yalındağ
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Murat Tanyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Benan Bayrakçi
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Gökhan Kalkan
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Başak N Akyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Erciyes, Kayseri, Turkey
| | - Alper Köker
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Tolga Köroğlu
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Ayşe B Anıl
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey.,Pediatric Intensive Care Unit, Department of Pediatrics, University of Izmir Katip Celebi, Izmir, Turkey
| | - Neslihan Zengin
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey
| | - Ener Ç Dinleyici
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Eylem Kıral
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Oğuz Dursun
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Akdeniz, Antalya, Turkey
| | | | - Peter Bartmann
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
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Kistler BM, Biruete A, Chapman-Novakofski K, Wilund KR. The Relationship Between Intradialytic Nutrition and Gastrointestinal Symptoms Using a Modified Version of the Gastrointestinal Symptom Rating Scale. J Ren Nutr 2018; 28:129-134. [PMID: 29471989 PMCID: PMC10436647 DOI: 10.1053/j.jrn.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 07/03/2017] [Accepted: 08/17/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Intradialytic nutrition has been shown to improve nutritional status in maintenance hemodialysis (HD) patients but remains controversial due in part to concerns over hemodynamic stability and gastrointestinal (GI) distress. There are limited data on the relationship between intradialytic nutrition and GI symptoms, possibly due to the lack of a validated tool. Therefore, we intended to validate a questionnaire to measure GI symptoms associated with a single HD treatment and determine the relationship between intradialytic nutrition and GI symptoms. DESIGN Cross-sectional study. Forty-eight maintenance HD patients. MAIN OUTCOME MEASURE GI symptoms and dietary intake during HD treatment. RESULTS In general, we found acceptable internal consistency (Cronbach's alpha >0.5, exception reflux domain) and repeatability in all 5 domains of a modified version of the Gastrointestinal Symptom Rating Scale. The prevalence of GI symptoms associated with a single HD treatment (generalized score greater than 1) was 54.2, 43.7, 6.2, 41.7, and 45.8% for the abdominal pain, indigestion, reflux, diarrhea, and constipation domains, respectively. More than two-thirds of patients chose to eat during treatment (168.6 ± 165.6 kcal) with the most commonly consumed items being candy, oral supplements, and cookies. There was no difference in GI symptoms among patients who did or did not eat (P > .05). However, the amount of total dietary fat and fiber consumed during treatment was associated with greater indigestion (P < .05) prior to accounting for outliers or multiple comparisons. CONCLUSION In this sample, the modified version of the Gastrointestinal Symptom Rating Scale was a generally valid tool for measuring GI symptoms associated with a single HD treatment. Patients who ate during treatment did not experience greater GI symptoms than those who did not; however, high amounts of fat and fiber may be associated with greater GI symptoms. Prospective trials should examine the relationship between GI symptoms and dietary intake during treatment in HD patients.
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Affiliation(s)
- Brandon M Kistler
- Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois; Department of Nutrition and Health Science, Ball State University, Muncie, Indiana.
| | - Annabel Biruete
- Division of Nutritional Science, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | | | - Kenneth R Wilund
- Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois; Division of Nutritional Science, University of Illinois at Urbana-Champaign, Urbana, Illinois
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Shang Q, Geng Q, Zhang X, Xu H, Guo C. The impact of early enteral nutrition on pediatric patients undergoing gastrointestinal anastomosis a propensity score matching analysis. Medicine (Baltimore) 2018; 97:e0045. [PMID: 29489656 PMCID: PMC5851715 DOI: 10.1097/md.0000000000010045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/19/2017] [Accepted: 02/07/2018] [Indexed: 01/02/2023] Open
Abstract
This study was conducted to assess the clinical advantages of early enteral nutrition (EEN) in pediatric patients who underwent surgery with gastrointestinal (GI) anastomosis.EEN has been associated with clinical benefits in various aspect of surgical intervention, including GI function recovery and postoperative complications reduction. Evaluable data documenting clinical advantages with EEN for pediatric patients after surgery with GI anastomosis are limited.We retrospectively reviewed the medical records of 575 pediatric patients undergoing surgical intervention with GI anastomosis. Among them, 278 cases were managed with EEN and the remaining cases were set as late enteral nutrition (LEN) group. Propensity score (PS) matching was conducted to adjust biases in patient selection. Enteral feeding related complications were evaluated with symptoms, including serum electrolyte abnormalities, abdominal distention, abdominal cramps, and diarrhea. Clinical outcomes, including GI function recovery, postoperative complications, length of hospital stay, and postoperative follow-up, were assessed according to EEN or LEN.Following PS matching, the baseline variables of the 2 groups were more comparable. There were no differences in the incidence of enteral feeding-related complications. EEN was associated with postoperative GI function recovery, including time to first defecation (3.1 ± 1.4 days for EEN vs 3.8 ± 1.0 days for LEN, risk ratio [RR], 0.62; 95% confidence interval [CI] 0.43-1.08, P = .042). A lower total episodes of complication, including infectious complications and major complications were noted in patients with EEN than in patients with LEN (117 [45.9%] vs 137 [53.7%]; OR, 0.73, 95% CI 0.52-1.03, P = .046). Mean postoperative length of stay in the EEN group was 7.4 ± 1.8 days versus 9.2 ± 1.4 days in the LEN group (P = .007). Furthermore, the incidence of adhesive small bowel obstruction was lower for patients with laxative administration compared with control, but no significant difference was attained (P = .092)EEN was safe and associated with clinical benefits, including shorten hospital stay, and reduced overall postoperative complications on pediatric patients undergoing GI anastomosis.
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Affiliation(s)
- Qingjuan Shang
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong province
| | - Qiankun Geng
- Department of Pediatric General Surgery, Children's Hospital
| | - Xuebing Zhang
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Hongfang Xu
- Department of Pediatric General Surgery, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Pathology, Linyi People's Hospital, Linyi, Shandong province
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University
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Mehta Y, Sunavala JD, Zirpe K, Tyagi N, Garg S, Sinha S, Shankar B, Chakravarti S, Sivakumar MN, Sahu S, Rangappa P, Banerjee T, Joshi A, Kadhe G. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2018; 22:263-273. [PMID: 29743765 PMCID: PMC5930530 DOI: 10.4103/ijccm.ijccm_3_18] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and Aim: Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. Methods: Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. Conclusion: This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols.
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Affiliation(s)
- Yatin Mehta
- Department of Critical Care, Institute of Critical Care and Anesthesiology, Medanta the Medicity, Gurugram, Haryana, India
| | - J D Sunavala
- Department of Critical Care Medicine, Jaslok Hospital, Mumbai, India
| | - Kapil Zirpe
- Department of Critical Care Medicine, Intensive Care and Neurotrauma - Stroke Unit, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Niraj Tyagi
- Department of Intensive Care and Emergency Medicine, Sir Gangaram Hospital, New Delhi, India
| | - Sunil Garg
- Department of Critical Care Medicine, Max Hospital, New Delhi, India
| | - Saswati Sinha
- Department of Critical Care Medicine, AMRI Hospitals, Kolkata, West Bengal, India
| | | | - Sanghamitra Chakravarti
- Department of Nutrition and Dietetics, Medica Superspeciality Hospital, Kolkata, West Bengal, India
| | - M N Sivakumar
- Department of Critical Care Medicine, KMCH, Coimbatore, Tamil Nadu, India
| | - Sambit Sahu
- Department of Critical care Medicine, KIMS Hospital, Hyderabad, Telangana, India
| | - Pradeep Rangappa
- Department of Intensive Care Medicine, Columbia Asia Hospitals, Bengaluru, Karnataka, India
| | - Tanmay Banerjee
- Department of Intensive Care Medicine, Medica Institute of Critical Care, Medica Super speciality Hospital, Kolkata, West Bengal, India
| | - Anshu Joshi
- Department of Scientific and Medical Affairs, Abbott Nutrition International, ANI-, Mumbai, India
| | - Ganesh Kadhe
- Department of Scientific and Medical Affairs, Abbott Nutrition International, ANI-, Mumbai, India
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Kistler BM, Benner D, Burrowes JD, Campbell KL, Fouque D, Garibotto G, Kopple JD, Kovesdy CP, Rhee CM, Steiber A, Stenvinkel P, ter Wee P, Teta D, Wang AY, Kalantar-Zadeh K. Eating During Hemodialysis Treatment: A Consensus Statement From the International Society of Renal Nutrition and Metabolism. J Ren Nutr 2018; 28:4-12. [DOI: 10.1053/j.jrn.2017.10.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 10/22/2017] [Indexed: 12/19/2022] Open
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Li W, Zheng B, Zhang S, Chen H, Zheng W, Chen C. Feasibility and outcomes of modified enhanced recovery after surgery for nursing management of aged patients undergoing esophagectomy. J Thorac Dis 2017; 9:5212-5219. [PMID: 29312728 DOI: 10.21037/jtd.2017.11.110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background The aim of this study was to determine whether a modified enhanced recovery after surgery (mERAS) protocol has a positive effect on the recovery of aged patients with esophageal cancer undergoing esophagectomy. Methods Consecutive patients were selected between January 2015 and June 2016 and were randomly assigned to a control group (traditional nursing care) or an observation group (mERAS protocol). We analyzed the outcomes of the patients, including surgical outcomes, postoperative complications, mental health status, and quality of life (QOL). Results Altogether, 110 patients who were >60 years of age were included in the study. They were evenly divided into two groups, with 55 patients in each. For the observation group, the thoracic drainage time was 1.07±0.26 days, first jejunal feeding time was at 11.71±1.81 h, time of first postoperative flatus was at 12.00±1.75 h, and length of postoperative stay was 8.31±1.25 days. There was no anastomotic leakage in the observation group, and the incidence of postoperative pulmonary infection was 5.45%. All the above indexes in the observation group were better than those for the patients receiving traditional nursing care. In addition, patients in the observation group had a lower level of mental suffering (P<0.05) and higher QOL (P<0.05). Conclusions mERAS protocols could result in better postoperative recovery and reduce postoperative complications in aged patients undergoing esophagectomy. Hence, mERAS protocols could be useful in reducing patients' mental suffering and improving their QOL.
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Affiliation(s)
- Wei Li
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Bin Zheng
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Shuliang Zhang
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Hao Chen
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Wei Zheng
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Chun Chen
- Thoracic Department, Fujian Medical University Union Hospital, Fuzhou 350001, China
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Abstract
The surgical critically ill patient is subject to a variable and complex metabolic response, which has detrimental effects on immunity, wound healing, and preservation of lean body muscle. The concept of nutrition support has evolved into nutrition therapy, whereby the primary objectives are to prevent oxidative cell injury, modulate the immune response, and attenuate the metabolic response. This review outlines the metabolic response to critical illness, describes nutritional risk; reviews the evidence for the role, dose, and timing of enteral and parenteral nutrition, and reviews the evidence for immunonutrition in the surgical intensive care unit.
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Cavalea AC, Heidel RE, Daley BJ, Lawson CM, Benton DA, Mcloughlin JM. Pneumatosis Intestinalis in Patients Receiving Tube Feeds. Am Surg 2017. [DOI: 10.1177/000313481708300830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.
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Affiliation(s)
- Alexander C. Cavalea
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Robert E. Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Christy M. Lawson
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Darrell A. Benton
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - James M. Mcloughlin
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
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Nguyen TAN, Abdelhamid YA, Phillips LK, Chapple LS, Horowitz M, Jones KL, Deane AM. Nutrient stimulation of mesenteric blood flow - implications for older critically ill patients. World J Crit Care Med 2017; 6:28-36. [PMID: 28224105 PMCID: PMC5295167 DOI: 10.5492/wjccm.v6.i1.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/16/2016] [Accepted: 01/02/2017] [Indexed: 02/06/2023] Open
Abstract
Nutrient ingestion induces a substantial increase in mesenteric blood flow. In older persons (aged ≥ 65 years), particularly those with chronic medical conditions, the cardiovascular compensatory response may be inadequate to maintain systemic blood pressure during mesenteric blood pooling, leading to postprandial hypotension. In older ambulatory persons, postprandial hypotension is an important pathophysiological condition associated with an increased propensity for syncope, falls, coronary vascular events, stroke and death. In older critically ill patients, the administration of enteral nutrition acutely increases mesenteric blood flow, but whether this pathophysiological response is protective, or precipitates mesenteric ischaemia, is unknown. There are an increasing number of older patients surviving admission to intensive care units, who are likely to be at increased risk of postprandial hypotension, both during, and after, their stay in hospital. In this review, we describe the prevalence, impact and mechanisms of postprandial hypotension in older people and provide an overview of the impact of postprandial hypotension on feeding prescriptions in older critically ill patients. Finally, we provide evidence that postprandial hypotension is likely to be an unrecognised problem in older survivors of critical illness and discuss potential options for management.
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Evidence based expert consensus for early rehabilitation in the intensive care unit. ACTA ACUST UNITED AC 2017. [DOI: 10.3918/jsicm.24_255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Besecker EM, Deiter GM, Pironi N, Cooper TK, Holmes GM. Mesenteric vascular dysregulation and intestinal inflammation accompanies experimental spinal cord injury. Am J Physiol Regul Integr Comp Physiol 2017; 312:R146-R156. [PMID: 27834292 PMCID: PMC5283935 DOI: 10.1152/ajpregu.00347.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/26/2016] [Accepted: 11/04/2016] [Indexed: 01/23/2023]
Abstract
Cervical and high thoracic spinal cord injury (SCI) drastically impairs autonomic nervous system function. Individuals with SCI at thoracic spinal level 5 (T5) or higher often present cardiovascular disorders that include resting systemic arterial hypotension. Gastrointestinal (GI) tissues are critically dependent upon adequate blood flow and even brief periods of visceral hypoxia triggers GI dysmotility. The aim of this study was to test the hypothesis that T3-SCI induces visceral hypoperfusion, diminished postprandial vascular reflexes, and concomitant visceral inflammation. We measured in vivo systemic arterial blood pressure and superior mesenteric artery (SMA) and duodenal blood flow in anesthetized T3-SCI rats at 3 days and 3 wk postinjury either fasted or following enteral feeding of a liquid mixed-nutrient meal (Ensure). In separate cohorts of fasted T3-SCI rats, markers of intestinal inflammation were assayed by qRT-PCR. Our results show that T3-SCI rats displayed significantly reduced SMA blood flow under all experimental conditions (P < 0.05). Specifically, the anticipated elevation of SMA blood flow in response to duodenal nutrient infusion (postprandial hyperemia) was either delayed or absent after T3-SCI. The dysregulated SMA blood flow in acutely injured T3-SCI rats coincides with abnormal intestinal morphology and elevation of inflammatory markers, all of which resolve after 3 wk. Specifically, Icam1, Ccl2 (MCP-1), and Ccl3 (MIP-1α) were acutely elevated following T3-SCI. Our data suggest that arterial hypotension diminishes mesenteric blood flow necessary to meet mucosal demands at rest and during digestion. The resulting GI ischemia and low-grade inflammation may be an underlying pathology leading to GI dysfunction seen following acute T3-SCI.
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Affiliation(s)
- Emily M Besecker
- Department of Neural & Behavioral Sciences, Penn State University College of Medicine, Hershey, Pennsylvania
- Department of Health Sciences, Gettysburg College, Gettysburg, Pennsylvania
| | - Gina M Deiter
- Department of Cellular and Molecular Physiology, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Nicole Pironi
- Department of Biology, Muhlenberg College, Allentown, Pennsylvania
| | - Timothy K Cooper
- Department of Comparative Medicine, Penn State University College of Medicine, Hershey, Pennsylvania Hershey, Pennsylvania; and
| | - Gregory M Holmes
- Department of Neural & Behavioral Sciences, Penn State University College of Medicine, Hershey, Pennsylvania;
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Merchan C, Altshuler D, Aberle C, Papadopoulos J, Schwartz D. Tolerability of Enteral Nutrition in Mechanically Ventilated Patients With Septic Shock Who Require Vasopressors. J Intensive Care Med 2016; 32:540-546. [DOI: 10.1177/0885066616656799] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose: Enteral nutrition (EN) is often held in patients receiving vasopressor support for septic shock. The rationale for this practice is to avoid mesenteric ischemia. The objective of this study is to evaluate the tolerability of EN in patients with septic shock who require vasopressor support and determine factors associated with tolerance of EN. Materials and Methods: This was a single-center retrospective review of adult patients admitted to the intensive care unit with a diagnosis of septic shock and an order for EN. The primary outcome was EN tolerance. Secondary outcomes included time to initiation of EN from the start of vasopressor(s), length of stay, and mortality. Results: A total of 120 patients were included. Sixty-two percent of patients tolerated EN. The most common reason for intolerance of EN was gastric residuals > 250 mL (74%). No reports of mesenteric ischemia were observed. A multivariate analysis demonstrated that patients with septic shock initiating EN within 48 hours and receiving norepinephrine-equivalent doses of 0.14 μg/kg/min or less were more likely to tolerate EN. Conclusion: Based on our observation, early EN may be tolerated and safely administered in patients with septic shock who are adequately fluid resuscitated and receive doses of < 0.14 μg/kg/min of norepinephrine equivalents.
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Affiliation(s)
- Cristian Merchan
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Diana Altshuler
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - Caitlin Aberle
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, New York University Langone Medical Center, New York, NY, USA
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - David Schwartz
- Department of Medicine, New York University School of Medicine, New York, NY, USA
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Perioperative feeding management of neonates with CHD: analysis of the Pediatric Cardiac Critical Care Consortium (PC4) registry. Cardiol Young 2015; 25:1593-601. [PMID: 26675610 DOI: 10.1017/s1047951115002474] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
UNLABELLED Introduction The optimal perioperative feeding strategies for neonates with CHD are unknown. In the present study, we describe the current feeding practices across a multi-institutional cohort. METHODS Inclusion criteria for this study were as follows: all neonates undergoing cardiac surgery admitted to the cardiac ICU for ⩾24 hours preoperatively between October, 2013 and July, 2014 in the Pediatric Cardiac Critical Care Consortium registry. RESULTS The cohort included 251 patients from eight centres. The most common diagnoses included the following: hypoplastic left heart syndrome (17%), coarctation/aortic arch hypoplasia (18%), and transposition of the great arteries (22%); 14% of the patients were <37weeks of gestational age. The median total hospital length of stay was 21 days (interquartile range (IQR) 14-35) and overall mortality was 8%. Preoperative feeding occurred in 133 (53%) patients. The overall preoperative feeding rates across centres ranged from 29 to 79%. Postoperative feeds started on median day 2 (IQR 1-4); for patients with hypoplastic left heart syndrome postoperative feeds started on median day 4. Postoperative feeds were initiated in 89 (35%) patients before extubation (range across centres: 21-61%). The median cardiac ICU discharge feeding volume was 108 cc/kg/day, varying across centres. The mean discharge weight was 280 g above birth weight, ranging from +100 to 430 g across centres. A total of 110 (44%) patients had discharge feeding tubes, ranging from 6 to 80% across centres, and 40/110 patients had gastrostomy/enterostomy tubes placed. In addition, eight (3.2%) patients developed necrotising enterocolitis - three preoperatively and five postoperatively. CONCLUSION In this cohort, neonatal feeding practices and outcomes appear to vary across diagnostic groups and institutions. Only half of the patients received preoperative enteral nutrition; almost half had discharge feeding tubes. Multi-institutional collaboration is necessary to determine feeding strategies associated with best clinical outcomes.
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Patel J, Kozeniecki M. PRO-viding Additional Evidence for Enteral Nutrition in Septic Shock. Nutr Clin Pract 2015; 30:844-5. [PMID: 26538059 DOI: 10.1177/0884533615598967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Brown AM, Carpenter D, Keller G, Morgan S, Irving SY. Enteral Nutrition in the PICU: Current Status and Ongoing Challenges. J Pediatr Intensive Care 2015; 4:111-120. [PMID: 31110860 DOI: 10.1055/s-0035-1559806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Malnutrition in the critically ill or injured child is associated with increased morbidities and mortality in the pediatric intensive care unit (PICU), whether present upon admission or acquired during the PICU stay. Particular subpopulations such as those with congenital heart disease or severe thermal injury are at highest risk for malnutrition which can worsen with illness progression. A growing body of evidence suggests the presence of a positive association between nutrition support during critical illness and patient outcomes. Enteral nutrition (EN), the preferred route of nutrient delivery, may be a crucial component of care provided in the PICU which modifies the response to critical illness or injury, resulting in improved outcomes. Numerous challenges exist in the delivery of the EN goal in critically ill children. These include accurate assessment of nutrient requirements, hemodynamic instability, feeding intolerance, feeding interruptions, and the lack of a standardized approach to nutrition support. This article describes the current state of the science and challenges related to EN prescription and delivery in the critically ill child. Suggestions for improving EN practice are then presented, in addition to a platform for further research inquiry.
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Affiliation(s)
- Ann-Marie Brown
- School of Nursing, The University of Akron, Akron, Ohio, United States.,Division of Critical Care, Akron Children's Hospital, Akron, Ohio, United States
| | - Debbie Carpenter
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Gerri Keller
- Department of Food Service and Nutrition, Akron Children's Hospital, Akron, Ohio, United States
| | - Sherry Morgan
- Biomedical Library, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Sharon Y Irving
- Department of Nursing, Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States.,School of Nursing, The University of Pennsylvania, Philadelphia, Pennsylvania, United States
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[Enteral nutrition therapy in critical care : Current knowledge, controversies, and practical implementation]. Med Klin Intensivmed Notfmed 2015; 111:330-40. [PMID: 26091922 DOI: 10.1007/s00063-015-0048-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 01/05/2023]
Abstract
Nutrition therapy is a cornerstone in critical care. Early enteral feeding in patients who are unable to meet caloric requirements from oral intake is associated with better clinical outcomes. However, there are still uncertainties about optimal timing, dose, and formula selection of enteral nutrition in critically ill patients. In the present article, an overview of current knowledge and practical strategies for successful implementation of enteral nutrition in intensive care patients is given.
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Streefkerk JO, Beishuizen A, Groeneveld ABJ. Gastric feeding intolerance is not caused by mucosal ischemia measured by intragastric air tonometry in the critically ill. Clin Nutr 2015; 35:731-4. [PMID: 26082336 DOI: 10.1016/j.clnu.2015.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/09/2015] [Accepted: 05/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastric mucosal ischemia may be a risk factor for gastrointestinal intolerance to early feeding in the critically ill. AIMS To study intragastric PCO2 air tonometry and gastric residual volumes (GRV) before and after the start of gastric feeding. METHODS This is a two-center study in intensive care units of a university and teaching hospital. Twenty-nine critically ill, consecutive and consenting patients scheduled to start gastric feeding were studied after insertion of a gastric tonometry catheter and prior to and after start of gastric feeding (500 ml over 1 h), when clinically indicated. RESULTS Blood gasometry and intragastric tonometry were performed prior to and 2 h after gastric feeding. The intragastric to arterial PCO2 gap (normal <8 mm Hg) was elevated in 41% of patients prior to feeding and measured (mean ± standard deviation) 13 ± 20 and 16 ± 23 mm Hg in patients with normal (<100 ml, 42 ± 34 ml, n = 19) and elevated GRV (250 ± 141 ml, n = 10, P = 0.75), respectively. After feeding, the gradient did not increase and measured 27 ± 25 and 23 ± 34 mm Hg, respectively (P = 0.80). CONCLUSION Gastric mucosal ischemia is not a major risk factor for intolerance to early gastric feeding in the critically ill.
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Affiliation(s)
- Jörn O Streefkerk
- Department of Intensive Care Medisch Centrum Haaglanden and Bronovo Ziekenhuis, Den Haag, Rotterdam, The Netherlands
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Veldsman L. Case Study: Small bowel perforation secondary to ileal tuberculosis: intensive care unit case study. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2015. [DOI: 10.1080/16070658.2015.11734525] [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]
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