Association between caloric adequacy and short-term clinical outcomes in critically ill patients using a weight-based equation: Secondary analysis of a cluster-randomized controlled trial

Background

There is controversy over the optimal energy delivery in intensive care units (ICUs). In this study, we aimed to evaluate the association between different caloric adequacy assessed by a weight-based equation and short-term clinical outcomes in a cohort of critically ill patients.

Methods

This is a secondary analysis of a cluster-randomized controlled trial (N = 2,772). The energy requirement was estimated as 25 kcal/kg of body weight. The study subjects were divided into three groups according to their caloric adequacy as calculated by the mean energy delivered from days 3 to 7 of enrollment divided by the estimated energy requirements: (1) received < 70% of energy requirement (hypocaloric), (2) received 70–100% of energy requirement (normocaloric), and (3) received > 100% of energy requirement (hypercaloric). Cox proportional hazards models were used to analyze the association between caloric adequacy and 28-day mortality and time to discharge alive from the ICU.

Results

A total of 1,694 patients were included. Compared with normocaloric feeding, hypocaloric feeding significantly increased the risk of 28-day mortality (hazard ratio [HR] = 1.590, 95% confidence interval [CI]: 1.162–2.176, p = 0.004), while hypercaloric feeding did not. After controlling for potential confounders, the association remained valid (adjusted HR = 1.596, 95% CI: 1.150–2.215, p = 0.005). The caloric adequacy was not associated with time to discharge alive from the ICU in the unadjusted and the adjusted models.

Conclusion

Energy delivery below 70% of the estimated energy requirement during days 3–7 of critical illness is associated with 28-day mortality.

Clinical trial registration

[https://www.isrctn.com/ISRCTN12233792], identifier [ISRCTN12233792].

Physician Compliance with Nutrition Support Team Recommendations: Effects on the Outcome of Treatment for Critically Ill Patients

Purpose: Attending physicians in Korea are aware of the existence of the Nutrition Support Team (NST), but even when the NST are consulted, compliance with their recommendations may be low. This study was performed to identify physicians’ compliance with the NST advice and how this affected the outcome of treatment for critically ill patients.Methods: This study was a retrospective observational study. Critically ill patients who were older than 18 years, younger than 90 years, and had been admitted and managed in the intensive care unit were selected for this study. Patients were assigned to either the compliance group or the non-compliance group according to physician compliance with the NST advice. Each group were compared using variables such as calorie supply, protein supply, laboratory findings, hospital stay, 30-day mortality, and survival rate.Results: The compliance group (81% of cases) was supplied with a significantly higher energy (1,146.36 ± 473.45 kcal vs. 832.45 ± 364.28 kcal, p < 0.01) and a significantly higher protein (55.00 ± 22.30 g/day vs. 42.98 ± 24.46 g/day, p = 0.04) compared with the non-compliance group. There was no significant difference in the basic demographics between groups, although the compliance group had a better outcome in the 30-day mortality rate (8% vs. 26%, p = 0.02), and in survival beyond 1 year (Crude model, hazard ratio: 2.42, CI: 1.11-5.29).Conclusion: Critically ill patients whose attending physician complied with the NST advice, received an increased energy intake and supply of protein which was positively associated with survival.

Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

BACKGROUND

Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support. Analysis of nutrition practices could improve nutrition management of this particular population.

METHODS

A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days. Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome.

RESULTS

A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections.

CONCLUSION

EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.

Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting

BACKGROUND

A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.

METHODS

This retrospective analysis (N = 61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n = 36) and post-implementation (n = 25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts.

RESULTS

Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P = 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8 ± 22.2% vs 55.9 ± 24.0%; P = 0.01) and energy requirements (93.4 ± 36.9% vs 69.6 ± 35.3%; P = 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition).

CONCLUSION

Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.

Enhanced Recovery Pathway for Complex Abdominal Wall Reconstruction

Ventral hernia repair with abdominal wall reconstruction can be a challenging endeavor, as patients commonly present not only with complex and recurrent hernias but also often with comorbidities that increase the risk of postoperative complications including wound morbidity and hernia recurrence, among other risks. By optimizing patient comorbidities in the preoperative setting and managing postoperative care in a regimented fashion, enhanced recovery after surgery pathways allow for a systematic approach to reduce complications and speed up recovery following ventral hernia repair.

Full Nutrition or Not?

Enteral nutrition (EN) is widely used in intensive care units around the world, but the optimal dosing strategy during the first week of critical illness is still controversial. Numerous studies in the past decade have provided conflicting recommendations regarding the roles of trophic and permissive/intentional underfeeding strategies. Further complicating effective medical decision making is the widespread, yet unintentional and persistent underdelivery of prescribed energy and protein, in addition to the trend for recommending ever-higher amounts of protein delivery. We postulate that the key to appropriate enteral strategy lies within an accurate and patient-specific assessment. Patients with a baseline high nutrition risk and those with increased nutrition demands, such as those with wounds, surgery, or burns, likely require full nutrition support, in contrast with medical patients, such as those with acute respiratory distress syndrome, who may selectively be appropriate for trophic strategies. In this analysis, we review several key trials for and against full EN in the first week of critical illness, as well as key issues such as the role of autophagy and immunonutrition in enteral dose selection.

Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit

BACKGROUND

Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting.

OBJECTIVES

To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship.

METHODS

A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index.

RESULTS

Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission.

CONCLUSION

The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.

Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A consensus statement

BACKGROUND & AIMS

Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia-Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia-Pacific and the Middle East.

METHODS

The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia-Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions.

RESULTS

Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU.

CONCLUSIONS

The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes.

Indirect Calorimetry: History, Technology, and Application

Measurement of energy expenditure is important in order to determine basal metabolic rate and inform energy prescription provided. Indirect calorimetry is the reference standard and clinically recommended means to measure energy expenditure. This article reviews the historical development, technical, and logistic challenges of indirect calorimetry measurement, and provides case examples for practicing clinicians. Formulae to estimate energy expenditure are highly inaccurate and reinforce the role of the indirect calorimetry and the importance of understanding the strength and limitation of the method and its application.

Controversies Surrounding Critical Care Nutrition: An Appraisal of Permissive Underfeeding, Protein, and Outcomes

Over the past few years, numerous studies have called into question the optimal dose, timing, composition, and advancement rate of nutrition during the early acute phase of critical illness. These studies suggest permissive underfeeding with slow advancement may be more beneficial than aggressive full feeding. These counterintuitive results were possibly explained by enhanced autophagy, less hyperglycemia, or prevention of refeeding syndrome. This review underscores the controversies surrounding permissive underfeeding, aims to answer whether permissive underfeeding is appropriate for all critically ill patients, describes the impact of optimal protein delivery on critical care outcomes, discusses nutrition risk, and cogitates on the impact of nutrition on critical care outcomes.

Critical Care Nutrition: Where's the Evidence?

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.

Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer

PURPOSE OF REVIEW

Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population.

RECENT FINDINGS

Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients.

SUMMARY

With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.

Effect of Calories Delivered on Clinical Outcomes in Critically Ill Patients: Systemic Review and Meta-analysis

Introduction:

International guidelines are promoting early enteral nutrition (EN) as a means of feeding critically ill adult patients to improve clinical outcomes. The question of how much calorie intake is enough to improve the outcomes still remained inconclusive. Therefore, we carried out a meta-analysis to evaluate the effect of low calorie (LC) versus high calorie (HC) delivery on critically ill patients' outcomes.

Methods:

We included randomized clinical trials (RCTs) that compared LC EN with or without supplemental parenteral nutrition with HC delivery in this meta-analysis irrespective of the site of nutritional delivery in the gastrointestinal tract. We searched PubMed, EMBASE, and Cochrane central register of controlled trials electronic databases to identify RCTs that compared the effects of initially different calorie intake in critical illness. The primary outcome was overall mortality.

Results:

This meta-analysis included 17 RCTs with a total of 3,593 participants. The result of analysis showed that there was no significant difference between the LC group and HC group in overall mortality (risk ratio [RR], 0.98; 95% confidence interval [CI], 0.87–1.10; P = 0.74; I² = 6%; P = 0.38), or new-onset pneumonia (RR, 0.92; 95% CI, 0.73–1.16, P = 0.46; I² = 38%, P = 0. 11).

Conclusion:

The current meta-analysis showed that there was no significant difference in mortality of critically ill patients initially between the two groups.