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Zheng L, Yuan X, Wang P, Zheng H, Lin J, Li C, Chen T, Tong Z, Liu Y, Ke L, Ma P, Li W. The impact of protein delivery on short-term and long-term clinical outcomes in critically ill patients: Protocol for a multicenter, prospective, observational study (The ACTION study). Clin Nutr ESPEN 2024; 64:1-6. [PMID: 39244157 DOI: 10.1016/j.clnesp.2024.09.001] [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: 05/28/2024] [Revised: 08/05/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND AND AIMS Nutrition therapy is a vital part of the management of critically ill patients. Efforts have been made to optimize nutrition therapy in the ICU setting, and it is argued that protein might be the most important substrate to deliver during critical illness. However, the impact of protein delivery on patient-centered outcomes, including short-term and long-term outcomes, is controversial. Moreover, previous studies showed that compliance with the guidelines is poor in practice, and the amounts of protein intake vary significantly among different hospitals. The objective of this study is to describe the current practice of protein delivery for critically ill patients and to investigate the association between different protein delivery amounts and approaches during ICU admission and multiple patient-centered outcomes (short-term and long-term). METHODS This is a multicenter, prospective, observational study conducted in 70 hospitals, aiming to recruit more than 1800 newly admitted critically ill patients who are expected to stay in ICU for at least 48 h. Data, including the baseline characteristics, illness severity scores, requirements of organ support therapy, and daily nutritional therapy, will be recorded until day 28 after enrollment unless discharge from the ICU or death occurs first. The key long-term clinical outcomes, like readmission post the index discharge and health-related quality of life, will be collected via telephone contact on Day 90 and Day 180 after recruitment. Quality of life will be assessed by the EuroQol five dimensions five-level questionnaire (EQ5D5L) visual analogue scale score. Apart from descriptive data, multivariate analyses adjusted for potential confounders will be applied to assess the association between protein intake during ICU stay and short-term and long-term clinical outcomes. ETHICS AND TRIAL REGISTRATION This study was reviewed and approved by the ethics committee of Jinling Hospital (2021NZKY-027-01) and the participating sites. The study was registered at the Chinese Clinical Trials Registry (ChiCTR2200067016) before enrollment.
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Affiliation(s)
- Lijiang Zheng
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Xin Yuan
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China
| | - Pingrong Wang
- Department of Critical Care Medicine, Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing 210002, China
| | - Hengyu Zheng
- Department of General Surgery, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Chao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Tao Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuxiu Liu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China; Research Institute of Critical Care Medicine and Emergency Rescue at Nanjing University, Nanjing, China.
| | - Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, Guizhou 550004, China.
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing 210002, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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Kim J, Shim Y, Choo YH, Kim HS, Kim YR, Ha EJ. Protein Requirement Changes According to the Treatment Application in Neurocritical Patients. J Korean Neurosurg Soc 2024; 67:451-457. [PMID: 37984964 PMCID: PMC11220411 DOI: 10.3340/jkns.2023.0176] [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: 08/25/2023] [Revised: 11/04/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE Exploring protein requirements for critically ill patients has become prominent. On the other hand, considering the significant impact of coma therapy and targeted temperature management (TTM) on the brain as well as systemic metabolisms, protein requirements may plausibly be changed by treatment application. However, there is currently no research on protein requirements following the application of these treatments. Therefore, the aim of this study is to elucidate changes in patients' protein requirements during the application of TTM and coma therapy. METHODS This study is a retrospective analysis of prospectively collected data from March 2019 to May 2022. Among the patients admitted to the intensive care unit, those receiving coma therapy and TTM were included. The patient's treatment period was divided into two phases (phase 1, application and maintenance of coma therapy and TTM; phase 2, tapering and cessation of treatment). In assessing protein requirements, the urine urea nitrogen (UUN) method was employed to estimate the nitrogen balance, offering insight into protein utilization within the body. The patient's protein requirement for each phase was defined as the amount of protein required to achieve a nitrogen balance within ±5, based on the 24-hour collection of UUN. Changes in protein requirements between phases were analyzed. RESULTS Out of 195 patients, 107 patients with a total of 214 UUN values were included. The mean protein requirement for the entire treatment period was 1.84±0.62 g/kg/day, which is higher than the generally recommended protein supply of 1.2 g/kg/day. As the treatment was tapered, there was a statistically significant increase in the protein requirement from 1.49±0.42 to 2.18±0.60 in phase 2 (p<0.001). CONCLUSION Our study revealed a total average protein requirement of 1.84±0.62 g during the treatment period, which falls within the upper range of the preexisting guidelines. Nevertheless, a notable deviation emerged when analyzing the treatment application period separately. Hence, it is recommended to incorporate considerations for the type and timing of treatment, extending beyond the current guideline, which solely accounts for the severity by disease.
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Affiliation(s)
- Jungook Kim
- Department of Traumatology, Gachon University Gil Medical Center, Incheon, Korea
| | - Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | | | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Im KM, Kim EY. Reducing In-Hospital and 60-Day Mortality in Critically Ill Patients after Surgery with Strict Nutritional Supplementation: A Prospective, Single-Labeled, Randomized Controlled Trial. Nutrients 2023; 15:4684. [PMID: 37960337 PMCID: PMC10648808 DOI: 10.3390/nu15214684] [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: 10/18/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/15/2023] Open
Abstract
Malnutrition in critically ill patients is a global concern, especially those who undergo abdominal surgery, as it is associated to higher infectious complications, prolonged hospital stays, and increased morbidity. Despite the importance of proper nutrition, guidelines remain broad, and practical implementation is often inadequate. We aimed to assess the effects of strict nutritional provision and investigate the appropriate target for nutrition support. A prospective, randomized controlled trial was conducted in critically ill patients admitted to intensive care units following abdominal surgery. The intervention group received targeted protein and calories, with consultation from a nutritional support team upon admission. In total, 181 patients in the intervention and 144 in the control group were analyzed. The intervention group demonstrated improved nutrition provision and subsequently better clinical outcomes, including a reduced 60-day mortality (4.4 versus 15.3, p = 0.001), postoperative complications (24.9 versus 47.2, p < 0.001), and in-hospital mortality (5 versus 17.4, p < 0.001). High modified nutrition risk in the critically ill scores [odds ratio (OR) = 2.658, 95% CI = 1.498-4.716] were associated with increased 60-day mortality, while active nutritional intervention (OR = 0.312, 95% CI = 0.111-0.873) was associated with lower mortality rates. Notably, the provision of targeted energy and protein alone did not exhibit a significant association with mortality outcomes.
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Affiliation(s)
- Kyoung Moo Im
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul 06591, Republic of Korea;
| | - Eun Young Kim
- Department of Surgery, Division of Trauma and Surgical Critical Care, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul 06591, Republic of Korea
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Schneider S, Hartmann K, Dörfelt R. Influence of intravenous 10% amino acids infusion on serum albumin concentration in hypoalbuminemic dogs. Front Vet Sci 2023; 10:1198534. [PMID: 37342623 PMCID: PMC10277565 DOI: 10.3389/fvets.2023.1198534] [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: 04/01/2023] [Accepted: 05/18/2023] [Indexed: 06/23/2023] Open
Abstract
Objective To evaluate the effect of parenteral amino acid application in hospitalized hypoalbuminemic dogs. Materials and methods Medical records of client-owned hypoalbuminemic dogs (albumin ≤ 25 g/L) were analyzed. Dogs receiving amino acids for only 1-2 days, receiving transfusions or surgery, or <6 months of age were excluded. Dogs were grouped as those receiving intravenous amino acids (AA, 80 dogs) over 3 days and longer, and those without additional amino acid treatment (CON, 78 dogs). Duration of hospitalization, albumin, and total protein concentrations were compared between groups by Mann-Whitney U test. Course of albumin and total protein concentration was evaluated by Friedman test and Dunn's multiple comparison test. Significance was set to p ≤ 0.05. Results Dogs in group AA received 10% amino acid solution intravenously over median 4 days (3-11 days). No significant differences regarding survival and adverse effects were observed between groups. Dogs of group AA had significantly longer duration of hospitalization (median 8 days; 3-33 days) compared to group CON dogs (median 6 days, 3-24 days; p < 0.001). Initial albumin concentration was lower in group AA compared to CON (p < 0.001). This difference was no longer present on day 2 (p = 0.134). Conclusions and clinical relevance Intravenous application of 10% amino acid solution in hypoalbuminemic dogs can improve albumin concentration after 2 days, but does not influence outcome.
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Kim JY, Wie GA, Ryu KA, Kim SY. Nutrition Support in Critically Ill Cancer Patient Receiving Extracorporeal Membrane Oxygenation: A Case Report. Clin Nutr Res 2023; 12:91-98. [PMID: 37214778 PMCID: PMC10193437 DOI: 10.7762/cnr.2023.12.2.91] [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: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Adequate nutritional support is crucial in preventing complications and improving outcomes in critically ill patients. Extracorporeal membrane oxygenation (ECMO) is a mode of supportive care for patients with respiratory and/or cardiac failure. ECMO patients frequently exhibit a hypermetabolic state characterized by protein catabolism and insulin resistance, which can lead to malnutrition. Nutritional therapy is a vital component of intensive care, but its optimal administration for ECMO patients is unknown. This case report aims to provide insights into effective nutritional management for critically ill patients undergoing ECMO therapy. The patient was a 72-year-old male with a history of gastric and lung cancer who underwent a lobectomy complicated by bronchopleural fistula, postoperative bleeding, pneumonia, and acute respiratory distress syndrome (ARDS). The patient's nutritional status was assessed indicating a high risk of malnutrition, using the modified Nutrition Risk in the Critically Ill (mNUTRIC) Score. Nutritional support was administered based on the recommendations of European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN), with energy requirements set at 25-30 kcal/kg/d and protein requirements set at 1.2-2.0 g/kg/day. The patient received parenteral nutrition until the enteral nutrition target amount was reached, with zinc supplements for wound healing. The study highlights the need for further research on proactive and effective nutritional support for ECMO patients to improve compliance and prognosis.
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Affiliation(s)
- Ji-Yeon Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Gyung-Ah Wie
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - Kyoung-A Ryu
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
| | - So-Young Kim
- Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
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Abstract
PURPOSE OF REVIEW Severe burn injury causes significant metabolic changes and demands that make nutritional support particularly important. Feeding the severe burn patient is a real challenge in regard to the specific needs and the clinical constraints. This review aims to challenge the existing recommendations in the light of the few recently published data on nutritional support in burn patients. RECENT FINDINGS Some key macro- and micro-nutrients have been recently studied in severe burn patients. Repletion, complementation or supplementation of omega-3 fatty acids, vitamin C, vitamin D, antioxidant micronutrients may be promising from a physiologic perspective, but evidence of benefits on hard outcomes is still weak due to the studies' design. On the contrary, the anticipated positive effects of glutamine on the time to discharge, mortality and bacteremias have been disproved in the largest randomized controlled trial investigating glutamine supplementation in burns. An individualized approach in term of nutrients quantity and quality may proof highly valuable and needs to be validated in adequate trials. The combination of nutrition and physical exercises is another studied strategy that could improve muscle outcomes. SUMMARY Due to the low number of clinical trials focused on severe burn injury, most often including limited number of patients, developing new evidence-based guidelines is challenging. More high-quality trials are needed to improve the existing recommendations in the very next future.
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Affiliation(s)
- Anne-Françoise Rousseau
- Intensive Care Department and Burn Center, University Hospital of Liège, Liège University, Liège, Belgium
| | - Olivier Pantet
- Intensive Care Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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Heyland DK, Patel J, Compher C, Rice TW, Bear DE, Lee ZY, González VC, O'Reilly K, Regala R, Wedemire C, Ibarra-Estrada M, Stoppe C, Ortiz-Reyes L, Jiang X, Day AG. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet 2023; 401:568-576. [PMID: 36708732 DOI: 10.1016/s0140-6736(22)02469-2] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND On the basis of low-quality evidence, international critical care nutrition guidelines recommend a wide range of protein doses. The effect of delivering high-dose protein during critical illness is unknown. We aimed to test the hypothesis that a higher dose of protein provided to critically ill patients would improve their clinical outcomes. METHODS This international, investigator-initiated, pragmatic, registry-based, single-blinded, randomised trial was undertaken in 85 intensive care units (ICUs) across 16 countries. We enrolled nutritionally high-risk adults (≥18 years) undergoing mechanical ventilation to compare prescribing high-dose protein (≥2·2 g/kg per day) with usual dose protein (≤1·2 g/kg per day) started within 96 h of ICU admission and continued for up to 28 days or death or transition to oral feeding. Participants were randomly allocated (1:1) to high-dose protein or usual dose protein, stratified by site. As site personnel were involved in both prescribing and delivering protein dose, it was not possible to blind clinicians, but patients were not made aware of the treatment assignment. The primary efficacy outcome was time-to-discharge-alive from hospital up to 60 days after ICU admission and the secondary outcome was 60-day morality. Patients were analysed in the group to which they were randomly assigned regardless of study compliance, although patients who dropped out of the study before receiving the study intervention were excluded. This study is registered with ClinicalTrials.gov, NCT03160547. FINDINGS Between Jan 17, 2018, and Dec 3, 2021, 1329 patients were randomised and 1301 (97·9%) were included in the analysis (645 in the high-dose protein group and 656 in usual dose group). By 60 days after randomisation, the cumulative incidence of alive hospital discharge was 46·1% (95 CI 42·0%-50·1%) in the high-dose compared with 50·2% (46·0%-54·3%) in the usual dose protein group (hazard ratio 0·91, 95% CI 0·77-1·07; p=0·27). The 60-day mortality rate was 34·6% (222 of 642) in the high dose protein group compared with 32·1% (208 of 648) in the usual dose protein group (relative risk 1·08, 95% CI 0·92-1·26). There appeared to be a subgroup effect with higher protein provision being particularly harmful in patients with acute kidney injury and higher organ failure scores at baseline. INTERPRETATION Delivery of higher doses of protein to mechanically ventilated critically ill patients did not improve the time-to-discharge-alive from hospital and might have worsened outcomes for patients with acute kidney injury and high organ failure scores. FUNDING None.
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Affiliation(s)
- Daren K Heyland
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; Department of Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Victoria C González
- Unidad de Soporte Metabólico y Nutricional Sanatorio Allende, Córdoba, Argentina
| | - Kevin O'Reilly
- King's College Hospital NHS Foundation Trust, London, UK
| | - Racquel Regala
- Clinical Nutrition, Legacy Salmon Creek Medical Center, Vancouver, WA, USA
| | - Courtney Wedemire
- Department of Food and Nutrition, Abbotsford Regional Hospital, Abbotsford, BC, Canada
| | - Miguel Ibarra-Estrada
- Unidad de Terapia Intensiva Hospital Civil Fray Antonio Alcalde Universidad de Guadalajara, Jalisco, México
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Luis Ortiz-Reyes
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Queen's University, Kingston, ON, Canada; Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada
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9
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Lindqvist C, Nordstedt P, Vidgren M, Nowak G. Protein intake early after liver transplantation and postoperative outcome: an observational study comparing two nutritional protocols. Nutrition 2022; 98:111635. [DOI: 10.1016/j.nut.2022.111635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/20/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022]
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Matsushima S, Yoshida M, Yokoyama H, Watanabe Y, Onodera H, Wakatake H, Saito H, Kimura M, Shibata S. Effects on physical performance of high protein intake for critically ill adult patients admitted to the intensive care unit: A retrospective propensity-matched analysis. Nutrition 2021; 91-92:111407. [PMID: 34388588 DOI: 10.1016/j.nut.2021.111407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study aimed to examine the effects of protein intake on physical performance in critically ill adult patients admitted to the intensive care unit (ICU). METHODS This was a retrospective cohort study of adult patients mechanically ventilated over 48 h in the ICU who were classified into two groups based on the amount of protein intake: >1.0 g/kg/d (high-protein group) or <1.0 g/kg/d (low-protein group). After adjustment for possible confounding factors with propensity score matching, we compared muscle strength at the time of ICU discharge and the rate of recovery to independent walking between the two groups. RESULTS One-to-one propensity score matching created 20 pairs. The high-protein group had significantly higher muscle strength than the low-protein group at the time of discharge from the ICU. In addition, the rate of recovery to independent walking before hospital discharge was higher in the high-protein group than the low-protein group (16 of 20 patients [80%] vs. 8 of 20 patients [40%]; P = 0.032). CONCLUSIONS Our findings indicate that a sufficient amount of protein intake may lead to a higher rate of recovery to independent walking before discharge from the hospital in critically ill patients admitted to the ICU. This finding is likely related to preserved muscle strength at the time of ICU discharge.
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Affiliation(s)
- Shinya Matsushima
- Department of Rehabilitation Medicine, St. Marianna University, School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Minoru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University, School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Hitoshi Yokoyama
- Department of Rehabilitation Medicine, St. Marianna University, School of Medicine Hospital, Kawasaki, Kanagawa, Japan
| | - Yosuke Watanabe
- Department of Rehabilitation Medicine, St. Marianna University, School of Medicine Hospital, Kawasaki, Kanagawa, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna, University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Haruaki Wakatake
- Department of Emergency and Critical Care Medicine, St. Marianna University, School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University, School of Medicine, Yokohama City Seibu Hospital, Yokohama, Kanagawa, Japan
| | - Masahiko Kimura
- Department of Physical Therapy, Faculty of Health Science, Kyorin University, Mitaka, Tokyo, Japan
| | - Shigeki Shibata
- Department of Physical Therapy, Faculty of Health Science, Kyorin University, Mitaka, Tokyo, Japan.
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Tedeschi-Jockers F, Reinhold S, Hollinger A, Tuchscherer D, Kiss C, Gantner L, Ledergerber K, Zimmermann S, Scheuzger J, Huber J, Siegemund M. A new high protein-to-energy enteral formula with a whey protein hydrolysate to achieve protein targets in critically ill patients: a prospective observational tolerability study. Eur J Clin Nutr 2021; 76:419-427. [PMID: 34168292 PMCID: PMC8223230 DOI: 10.1038/s41430-021-00956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 05/16/2021] [Accepted: 05/28/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Current guidelines and expert recommendations stress the need to implement enteral feeds with a higher protein-to-energy ratio to meet protein requirements as recommended while avoiding gastrointestinal side effects and energy overfeeding in ICU patients. MATERIALS AND METHODS Prospective tolerability study in 18 critically ill patients with a high protein formula (high protein-to-energy (HP:E) formula = Fresubin® Intensive; HPG) compared to a contemporary matched conventional therapy group (CTG). The primary outcome was GI intolerance defined as ≥300 ml daily gastric residual volume (GRV), vomiting, or diarrhea on days 1 and 2. Secondary outcomes were the percentage of patients reaching their protein target on day 4 and overall protein intake. RESULTS Groups were comparable regarding demographic characteristics, disease severity, organ failures, mechanical ventilation, and NUTRIC score at baseline. Eighteen patients completed the 4-day feeding period. The number of events of GRV of ≥300 ml/day was equal in both groups (33.3%). The incidence of diarrhea and vomiting was low in the HPG (two patients concerned). EN did not need to be discontinued due to intolerance in any group. Seventy-two percent of patients reached protein targets ≥1.3 g/kgBW/d within 4 days after initiation of enteral feeding, which was superior to the CTG (33%). Post-hoc testing showed group differences of protein intake between HPG and CTG were significant at t = 72 h and t = 96 h. Energy targets were met in both groups. CONCLUSION The HP:E formula containing 33% whey protein hydrolysate is well tolerated in this tolerability study. Due to the HP:E ratio protein targets can be reached faster. Larger randomized trials are needed to confirm preliminary results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02678325. Registered 2 May 2016.
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Affiliation(s)
| | - Simona Reinhold
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.
| | | | - Caroline Kiss
- Department of Clinical Nutrition, University Department of Geriatric Medicine Felix Platter, Basel, Switzerland
| | - Lukas Gantner
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | | | | | - Jonas Scheuzger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Jan Huber
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
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Hsu CC, Sun CY, Tsai CY, Chen MY, Wang SY, Hsu JT, Yeh CN, Yeh TS. Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice. J Multidiscip Healthc 2021; 14:1107-1117. [PMID: 34017176 PMCID: PMC8131070 DOI: 10.2147/jmdh.s306350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/23/2021] [Indexed: 12/29/2022] Open
Abstract
The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.
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Affiliation(s)
- Chih-Chieh Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Ci-Yuan Sun
- Division of Colon & Rectal Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,Chang Gung University, Taoyuan, 333, Taiwan
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Terblanche E, Remmington C. Observational study evaluating the nutritional impact of changing from 1% to 2% propofol in a cardiothoracic adult critical care unit. J Hum Nutr Diet 2020; 34:413-419. [PMID: 33211347 DOI: 10.1111/jhn.12835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Nutritional support in the critically ill aims to avoid under and overfeeding, adjusting to changes in energy expenditure during critical illness. The sedation propofol provides significant fat and energy load. We investigated whether changing from 1% to a 2% propofol, would decrease non-nutritional energy, avoid energy overfeeding and increase the amount of protein delivered. METHODS A retrospective observational study was performed. The primary outcome was protein delivery. Secondary outcomes were energy from propofol fat and the total energy delivered from nutrition and propofol. RESULTS In total, 100 patients were investigated, with 50 patients in each group. The propofol dose was comparable for each group. The nutrition energy prescribed was significantly less for the 1% compared to 2% group, taking the energy from propofol into consideration. Both groups had similar protein targets, although the amount delivered was significantly higher in the 2% group. Thirty-six percent of individuals receiving 1% exceeded 45% of total energy from fat. The poor delivery of nutrition resulted in inadequate energy and protein, irrespective of propofol dose. CONCLUSIONS We investigated the impact of propofol on energy overfeeding and under delivery of protein, and highlighted suboptimal nutritional provision. Work is needed to investigate the harm that high-fat delivery may pose in light of poor nutrition delivery.
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Affiliation(s)
- Ella Terblanche
- Adult Critical Care Unit, The Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, UK
| | - Chris Remmington
- Adult Critical Care Unit, The Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, UK
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14
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Kim TJ, Park SH, Jeong HB, Ha EJ, Cho WS, Kang HS, Kim JE, Ko SB. Optimizing Nitrogen Balance Is Associated with Better Outcomes in Neurocritically Ill Patients. Nutrients 2020; 12:nu12103137. [PMID: 33066539 PMCID: PMC7602201 DOI: 10.3390/nu12103137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/07/2020] [Accepted: 10/11/2020] [Indexed: 12/12/2022] Open
Abstract
Marked protein catabolism is common in critically ill patients. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better outcomes in the neurointensive care unit (NICU) patients. A total of 175 patients admitted to the NICU between July 2017 and December 2018 were included. Nitrogen balance was measured after NICU admission and measurements were repeated in 77 patients. The outcomes were compared according to initial nitrogen balance results and improvement of nitrogen balance on follow-up measurements. A total of 140 (80.0%) patients had a negative nitrogen balance on initial assessments. The negative balance group had more events of in-hospital mortality and poor functional outcome at three months. In follow-up measurement patients, 39 (50.6%) showed an improvement in nitrogen balance. The improvement group had fewer events of in-hospital mortality (p = 0.047) and poor functional outcomes (p = 0.046). Moreover, improvement of nitrogen balance was associated with a lower risk of poor functional outcomes (Odds ratio, 0.247; 95% confidence interval, 0.066–0.925, p = 0.038). This study demonstrated that a significant proportion of patients in the NICU were under protein hypercatabolism. Moreover, an improvement in protein balance was related to improved outcomes in neurocritically ill patients. Further studies are needed to confirm the relationship between protein balance and outcomes.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (T.J.K.); (H.-B.J.)
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Korea;
| | - Soo-Hyun Park
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea;
| | - Hae-Bong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (T.J.K.); (H.-B.J.)
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Korea;
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (W.S.C.); (H.-S.K.); (J.E.K.)
| | - Won Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (W.S.C.); (H.-S.K.); (J.E.K.)
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (W.S.C.); (H.-S.K.); (J.E.K.)
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (W.S.C.); (H.-S.K.); (J.E.K.)
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (T.J.K.); (H.-B.J.)
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Korea;
- Correspondence: ; Tel.: +82-2-2072-2278
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15
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Zaher SA, Al-Subaihi R, Al-Alshaya A, Al-Saggaf M, Al Amoudi MO, Babtain H, Neyaz A. Pilot Study to Investigate Enteral Feeding Practices and the Incidence of Underfeeding Among Mechanically Ventilated Critically Ill Patients at a Specialist Tertiary Care Hospital in Saudi Arabia. JPEN J Parenter Enteral Nutr 2020; 45:1327-1337. [PMID: 32924151 DOI: 10.1002/jpen.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/29/2020] [Accepted: 09/08/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Enteral nutrition (EN) is an essential therapeutic intervention. Many studies internationally have reviewed feeding practices in intensive care units (ICUs) and recorded the incidence of underfeeding in these settings, yet none were performed in the Middle East, including Saudi Arabia. The purpose of the study is to assess the adequacy of EN delivery and investigate the enteral feeding practices in the ICU at a specialized tertiary care hospital in Saudi Arabia. METHODS In this observational study, we prospectively monitored energy and protein delivery for 6 consecutive days in critically ill patients. Malnutrition was assessed by Nutrition Risk Screening (NRS-2002) scores. Underfeeding was identified by comparing the intake against the calculated requirements. Patients were categorized into early and late EN starters to investigate whether the time of EN initiation impacts the cumulative nutrition intake. RESULTS This study included 43 patients. About 44% (19 of 43) of the patients were malnourished on admission to ICU, and the prevalence of underfeeding was >90%. The median cumulative intake of energy and protein was 39% and 31% of the estimated requirements, respectively. Patients who started early EN had statistically higher cumulative energy and protein intake (P-value = .00). Patients treated with inotropes received less energy and protein compared with those who did not receive inotropes (P-value = .00). Higher NRS-2002 score was associated with fewer ventilation-free hours (r = -0.369, P-value = .045). CONCLUSION Protein underfeeding remains a significant problem in ICU settings. The time of EN initiation plays a major role in determining when the nutrition requirements will be met. Therefore, it is crucial to implement effective feeding protocols to ensure early initiation of EN when permissible.
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Affiliation(s)
- Sara A Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Raghad Al-Subaihi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Aeshah Al-Alshaya
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Manar Al-Saggaf
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Mariam O Al Amoudi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Hala Babtain
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Arwa Neyaz
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
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16
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Protein delivery in intermittent and continuous enteral nutrition with a protein-rich formula in critically ill patients-a protocol for the prospective randomized controlled proof-of-concept Protein Bolus Nutrition (Pro BoNo) study. Trials 2020; 21:740. [PMID: 32843075 PMCID: PMC7449093 DOI: 10.1186/s13063-020-04635-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 07/27/2020] [Indexed: 01/03/2023] Open
Abstract
Background Critically ill patients rapidly develop muscle wasting resulting in sarcopenia, long-term disability and higher mortality. Bolus nutrition (30–60 min period), whilst having a similar incidence of aspiration as continuous feeding, seems to provide metabolic benefits through increased muscle protein synthesis due to higher leucine peaks. To date, clinical evidence on achievement of nutritional goals and influence of bolus nutrition on skeletal muscle metabolism in ICU patients is lacking. The aim of the Pro BoNo study (Protein Bolus Nutrition) is to compare intermittent and continuous enteral feeding with a specific high-protein formula. We hypothesise that target quantity of protein is reached earlier (within 36 h) by an intermittent feeding protocol with a favourable influence on muscle protein synthesis. Methods Pro BoNo is a prospective randomised controlled study aiming to compare the impact of intermittent and continuous enteral feeding on preventing muscle wasting in 60 critically ill patients recruited during the first 48 h after ICU admission. The primary outcome measure is the time until the daily protein target (≥ 1.5 g protein/kg bodyweight/24 h) is achieved. Secondary outcome measures include tolerance of enteral feeding and evolution of glucose, urea and IGF-1. Ultrasound and muscle biopsy of the quadriceps will be performed. Discussion The Basel Pro BoNo study aims to collect innovative data on the effect of intermittent enteral feeding of critically ill patients on muscle wasting. Trial registration ClinicalTrials.gov NCT03587870. Registered on July 16, 2018. Swiss National Clinical Trials Portal SNCTP000003234. Last updated on July 24, 2019.
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17
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Stoppe C, Wendt S, Mehta NM, Compher C, Preiser JC, Heyland DK, Kristof AS. Biomarkers in critical care nutrition. Crit Care 2020; 24:499. [PMID: 32787899 PMCID: PMC7425162 DOI: 10.1186/s13054-020-03208-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
The goal of nutrition support is to provide the substrates required to match the bioenergetic needs of the patient and promote the net synthesis of macromolecules required for the preservation of lean mass, organ function, and immunity. Contemporary observational studies have exposed the pervasive undernutrition of critically ill patients and its association with adverse clinical outcomes. The intuitive hypothesis is that optimization of nutrition delivery should improve ICU clinical outcomes. It is therefore surprising that multiple large randomized controlled trials have failed to demonstrate the clinical benefit of restoring or maximizing nutrient intake. This may be in part due to the absence of biological markers that identify patients who are most likely to benefit from nutrition interventions and that monitor the effects of nutrition support. Here, we discuss the need for practical risk stratification tools in critical care nutrition, a proposed rationale for targeted biomarker development, and potential approaches that can be adopted for biomarker identification and validation in the field.
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Affiliation(s)
- Christian Stoppe
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Sebastian Wendt
- 3CARE—Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania and Clinical Nutrition Support Service, Hospital of the University of Pennsylvania, Philadelphia, PA USA
| | - Jean-Charles Preiser
- Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, B-1070 Brussels, Belgium
| | - Daren K. Heyland
- Department of Critical Care Medicine, Queen’s University, Angada 4, Kingston, ON K7L 2V7 Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7 Canada
| | - Arnold S. Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Faculty of Medicine, Departments of Medicine and Critical Care, Research Institute of the McGill University Health Centre, 1001 Décarie Blvd., EM3.2219, Montreal, QC H4A 3J1 Canada
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18
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Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial. Nutr Res Rev 2020; 33:312-320. [PMID: 32669140 DOI: 10.1017/s0954422420000165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
While medical nutrition therapy is an essential part of the care for critically ill patients, uncertainty exists about the right form, dosage, timing and route in relation to the phases of critical illness. As enteral nutrition (EN) is often withheld or interrupted during the intensive care unit (ICU) stay, combined EN and parenteral nutrition (PN) may represent an effective and safe option to achieve energy and protein goals as recommended by international guidelines. We hypothesise that critically ill patients at high nutritional risk may benefit from such a combined approach during their stay on the ICU. Therefore, we aim to test if an early combination of EN and high-protein PN (EN+PN) is effective in reaching energy and protein goals in patients at high nutritional risk, while avoiding overfeeding. This approach will be tested in the here-presented EFFORTcombo trial. Nutritionally high-risk ICU patients will be randomised to either high (≥2·2 g/kg per d) or low protein (≤1·2 g/kg per d). In the high protein group, the patients will receive EN+PN; in the low protein group, patients will be given EN alone. EN will be started in accordance with international guidelines in both groups. Efforts will be made to reach nutrition goals within 48-96 h. The efficacy of the proposed nutritional strategy will be tested as an innovative approach by functional outcomes at ICU and hospital discharge, as well as at a 6-month follow-up.
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19
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McKendry J, Thomas ACQ, Phillips SM. Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies. Nutr Clin Pract 2020; 35:607-616. [PMID: 32578900 DOI: 10.1002/ncp.10540] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022] Open
Abstract
Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.
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Affiliation(s)
- James McKendry
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Aaron C Q Thomas
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Stuart M Phillips
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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20
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Javid Z, Shadnoush M, Khadem-Rezaiyan M, Mohammad Zadeh Honarvar N, Sedaghat A, Hashemian SM, Ardehali SH, Nematy M, Pournik O, Beigmohammadi MT, Safarian M, Moradi Moghaddam O, Khoshfetrat M, Zand F, Mohammad Alizadeh A, Kosari Monfared M, Mazaheri Eftekhar F, Mohamadi Narab M, Taheri AS, Babakhani K, Foroutan B, Jamialahmadi T, Jabbarzadeh Gangeh B, Meshkani M, Kimiaee F, Norouzy A. Nutritional adequacy in critically ill patients: Result of PNSI study. Clin Nutr 2020; 40:511-517. [PMID: 32711949 DOI: 10.1016/j.clnu.2020.05.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Critically ill patients are provided with the intensive care medicine to prevent further complications, including malnutrition, disease progression, and even death. This study was intended to assess nutritional support and its' efficacy in the Intensive Care Units (ICUs) of Iran. METHODS This cross-sectional study assessed 50 ICU's patients out of 25 hospitals in the 10 major regions of Iran's health system and was performed using the multistage cluster sampling design. The data were collected from patient's medical records, ICU nursing sheets, patients or their relatives from 2017 to 2018. Nutritional status was investigated by modified NUTRIC score and food frequency checklist. RESULTS This study included 1321 ICU patients with the mean age of 54.8 ± 19.97 years, mean mNUTRIC score of 3.4 ± 2.14, and malnutrition rate of 32.6%. The mean time of first feeding was the second day and most of patients (66%) received nutrition support, mainly through enteral (57.2%) or oral (37%) route during ICU stay. The patients received 59.2 ± 37.78 percent of required calorie and 55.5 ± 30.04 percent of required protein. Adequate intake of energy and protein was provided for 16.2% and 10.7% of the patients, respectively. The result of regression analysis showed that the odds ratio of mNUTRIC score was 0.85 (95% confidence interval [CI] = 0.74-0.98) and APACHE II was 0.92 (95%CI = 0.89-0.95) for the prediction of energy deficiency. Nutrition intake was significantly different from patient's nutritional requirements both in terms of energy (p < 0.001) and protein (p < 0.001). Also, mean mNUTRIC score varied notably (p = 0.011) with changing in energy intake, defined as underfeeding, adequate feeding, and overfeeding. CONCLUSION The present findings shown that, provided nutritional care for ICU patients is not adequate for their requirements and nutritional status.
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Affiliation(s)
- Zeinab Javid
- Student Research Committee, Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdi Shadnoush
- Semnan University of Medical Sciences, Semnan, Iran; Department of Clinical Nutrition, Faculty of Nutrition & Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Khadem-Rezaiyan
- Department of Community Medicine and Public Health, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Niyaz Mohammad Zadeh Honarvar
- Department of Cellular and Molecular Nutrition, School of Nutritional Sciences & Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Sedaghat
- Faculty of Critical Care Medicine, Lung Disease Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Mohammadreza Hashemian
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Hossein Ardehali
- Department of Anesthesiology &Critical care, Shohadaye - Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Nematy
- Biochemistry and Nutrition Department, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Pournik
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran; Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Taghi Beigmohammadi
- Department of Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Safarian
- Biochemistry and Nutrition Department, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Moradi Moghaddam
- Trauma and Injury Research Center & Critical Care Department, Rasoul-e-Akram Complex Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Masoum Khoshfetrat
- Anesthesiology and Critical Care Department of Anesthesiology and Intensive Care Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afshin Mohammad Alizadeh
- Department of Bone Marrow Transplantation, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Maryam Mohamadi Narab
- Department of Nutrition, Sciences and Research Branch, Islamic Azad University, Tehran, Iran
| | - Arefe Sadat Taheri
- Kowsar Hospital, Semnan University of Medical Sciences and Health Services, Semnan, Iran
| | - Khatereh Babakhani
- Department of Nutrition, Sciences and Research Branch, Islamic Azad University, Tehran, Iran
| | - Behnam Foroutan
- Student Research Committee, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran
| | - Tannaz Jamialahmadi
- Student Research Committee, Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mehrnoush Meshkani
- Department of Nutrition, Sciences and Research Branch, Islamic Azad University, Tehran, Iran
| | - Fahime Kimiaee
- Department of Nutrition Sciences, Varastegan Institute for Medical Sciences, Mashhad, Iran
| | - Abdolreza Norouzy
- Biochemistry and Nutrition Department, Mashhad University of Medical Sciences, Mashhad, Iran.
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21
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Hoffer LJ. Understanding Equipoise. Nutr Clin Pract 2020; 35:495-498. [PMID: 32347586 DOI: 10.1002/ncp.10492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 12/10/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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22
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ApSimon M, Johnston C, Winder B, Cohen SS, Hopkins B. Narrowing the Protein Deficit Gap in Critically Ill Patients Using a Very High-Protein Enteral Formula. Nutr Clin Pract 2020; 35:533-539. [PMID: 32083356 DOI: 10.1002/ncp.10472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Protein deficits have been associated with longer intensive care unit (ICU) stays and increased mortality. Current view suggests if protein goals are met, meeting full energy targets may be less important and prevent deleterious effects of overfeeding. We proposed a very-high protein (VHP) enteral nutrition (EN) formula could provide adequate protein, without overfeeding energy, in the first week of critical illness. METHODS This was a retrospective study of medical/surgical ICU patients receiving EN exclusively for ≥5 days during the first week of ICU admission. Twenty participants received standard EN; 20 participants received the VHP-EN formula (1 kcal/mL, 37% protein). Protein and energy prescribed/received, gastrointestinal tolerance, and feeding interruptions were examined. RESULTS Forty ICU patients [average Acute Physiology and Chronic Health Evaluation II score of 20.1] were included. Protein prescribed and received was significantly higher in the VHP group vs the standard EN group (135.5 g/d ± 22.9 vs 111.4 g/d ± 25; P = .003 and 112.2 g/d ± 27.8 vs 81.7 g/d ± 16.7, respectively; P = .002). Energy prescribed and received was similar between groups (1696 kcal/d ± 402 vs 1893 kcal/d ± 341, respectively; P = .101 and 1520 kcal/d ± 346 vs 1506 ± 380 kcal/d; P = .901). There were no differences in EN tolerance (P = .065) or feeding interruptions (P = .336). CONCLUSIONS Use of a VHP formula in ICU patients resulted in higher protein intakes without overfeeding energy or use of modular protein in the first 5 days of exclusive EN.
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Affiliation(s)
- Michele ApSimon
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | - Carrie Johnston
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | - Barb Winder
- Hamilton Health Sciences, Department of Critical Care, Hamilton General Hospital Site, Hamilton, Ontario, Canada
| | | | - Bethany Hopkins
- Medical Affairs, Nestlé Health Science Canada, North York, Ontario, Canada
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O’Keefe GE, Shelton M, Qiu Q, Araujo-Lino JC. Increasing Enteral Protein Intake in Critically Ill Trauma and Surgical Patients. Nutr Clin Pract 2019; 34:751-759. [PMID: 30729565 PMCID: PMC10980575 DOI: 10.1002/ncp.10256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Published guidelines recommend providing at least 2 g/kg/d of protein for critically ill surgical patients. It may be difficult to achieve this level of intake using standard enteral formulas, thus necessitating protein or amino acid supplementation. Herein, we report our approach to enteral protein supplementation and its relationship with urinary nitrogen excretion and serum transthyretin concentrations. METHODS This was a retrospective cohort study in which we reviewed critically ill trauma and surgical patients treated with supplemental enteral protein according to a protocol aiming to deliver a total of 2 g/kg/d of protein. We collected detailed nutrition data over a 2-week period after admission and obtained additional data through discharge to determine caloric and protein intake as well as complications. We also compared urine nitrogen excretion and transthyretin concentrations between these patients and a control group who did not receive supplemental protein. RESULTS Fifty-three subjects received early protein supplementation. Formula and protein supplement each provided ≈1.2 g/kg/d of protein by intensive care unit day 4. This resulted in a median total protein intake of 2.2 g/kg/d through day 14. One patient developed acute kidney injury, and 1 patient had 3 episodes of vomiting. By the third week, serum transthyretin concentrations increased to a median of 21 mg/dL compared with 13 mg/dL in subjects not receiving early supplementation. CONCLUSION It is safe to deliver supplemental protein enterally to critically ill surgical and trauma patients and reach 2 g/kg/d of protein intake during the first week of illness.
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Affiliation(s)
- Grant E. O’Keefe
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | | | - Qian Qiu
- Harborview Injury Prevention and Research Center, Seattle, Washington, USA
| | - Jose Cruz Araujo-Lino
- Harborview Injury Prevention and Research Center, Seattle, Washington, USA
- Department of Surgery, University of Washington, Harborview Injury Prevention and Research Center and Harborview Medical Center, Seattle, Washington, USA
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Gropper S, Hunt D, Chapa DW. Sarcopenia and Psychosocial Variables in Patients in Intensive Care Units: The Role of Nutrition and Rehabilitation in Prevention and Treatment. Crit Care Nurs Clin North Am 2019; 31:489-499. [PMID: 31685115 DOI: 10.1016/j.cnc.2019.07.004] [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] [Indexed: 01/08/2023]
Abstract
Critical illness leads to decline in muscle mass that promotes decline in physical function and psychological function and may lead to cognitive decline or dementia. Nurses are key to driving the multidisciplinary interventions that prevent protein loss and promote positive outcomes for critically ill patients.
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Affiliation(s)
- Sareen Gropper
- Christine E. Lynn College of Nursing, Florida Atlantic University, Building 84, Office 322, 777 Glades Road, Boca Raton, FL 33431, USA
| | - Dennis Hunt
- Florida Gulf Coast University, 10501 FGCU Boulevard South, Fort Myers, FL 33965, USA
| | - Deborah W Chapa
- Lee Health, 8925 Colonial Center Drive, Building A, Suite 1000, Fort Myers, FL 33905, USA.
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25
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Hopkins B, Cohen SS, Irvin SR, Alberda C. Achieving Protein Targets in the ICU Using a Specialized High-Protein Enteral Formula: A Quality Improvement Project. Nutr Clin Pract 2019; 35:289-298. [PMID: 31240750 DOI: 10.1002/ncp.10364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To meet protein needs in critical illness (CI), guidelines suggest ≥1.2-2.5 g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7 g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience. METHODS This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m2 ), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded. RESULTS Forty-four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5-200) or 1.9 g/kg/d (1.5-2.5). Average protein delivered was 116.9 g/d (33.5-180) or 1.6 g/kg/d (0.4-2.4). Seventy-five percent to 83% of patients received ≥80% prescribed protein on days 2-5. Average energy prescribed was 1638.6 kcal/d (990-2500) or 17.8 kcal/kg (11-26). Average energy delivered was 1523.9 kcal/d (693.0-2557.5) or 17.3 kcal/kg/d (1.35-64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38 (86%) patients. The most common reasons to prescribe the formula were obesity and use of fat-based medications. CONCLUSIONS We demonstrated in a QI study that a high-protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding.
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Affiliation(s)
- Bethany Hopkins
- Medical Affairs, Nestlé Health Science Canada, North York, Ontario, Canada
| | | | | | - Cathy Alberda
- Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada
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Ribeiro HS, Coury NC, de Vasconcelos Generoso S, Lima AS, Correia MITD. Energy Balance and Nutrition Status: A Prospective Assessment of Patients Undergoing Liver Transplantation. Nutr Clin Pract 2019; 35:126-132. [DOI: 10.1002/ncp.10323] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Helem Sena Ribeiro
- Surgery Post Graduation Program; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - Nayhara Castro Coury
- Nutrition Department; Nursing School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | | | - Agnaldo Soares Lima
- Alfa Institute of Gastroenterology; Hospital of Clinics; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
| | - Maria Isabel Toulson Davisson Correia
- Surgery Post Graduation Program; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
- Alfa Institute of Gastroenterology; Hospital of Clinics; Medical School; Universidade Federal de Minas Gerais; Belo Horizonte Brazil
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27
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Patel JJ, Rice T, Compher C, Heyland DK. Do We Have Clinical Equipoise (or Uncertainty) About How Much Protein to Provide to Critically Ill Patients? Nutr Clin Pract 2019; 35:499-505. [PMID: 31175689 DOI: 10.1002/ncp.10320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The current recommendation for protein dose in critically ill patients is 1.2-2.0 g/kg/d. Despite this recommendation, there is significant variation in the amount of protein prescribed and delivered worldwide. We contend clinical equipoise, or a state of genuine uncertainty about 2 (dosing) strategies, exists because guideline-based recommendations for protein dose in critically ill patients are rooted in a weak evidentiary base, leaving the clinician with no good basis for choosing a lower or higher protein dose. We outline evidence for and against high protein dose and introduce a pragmatic, registry-based, multicenter, randomized controlled trial, known as EFFORT, which aims to resolve the high vs low protein dose controversy.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Todd Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Charlene Compher
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daren K Heyland
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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28
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Freitas MMTD, Stanich P, Diccini S. Status and nutritional therapy in elective and emergency neurosurgery patients. Rev Bras Enferm 2019; 72:73-80. [PMID: 30916270 DOI: 10.1590/0034-7167-2017-0491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/06/2018] [Indexed: 12/13/2022] Open
Abstract
OBJEVECT To evaluate the Nutritional Status (NS) and follow the Enteral Nutritional Therapy (ENT) of patients in neurosurgical intervention. METHOD Cohort study in emergency or elective surgery patients with exclusive ENT. Anthropometric measurements (Arm Circumference (AC and Triceps Skinfold (TSF)) were measured on the first, seventh and 14th day. For the ENT monitoring, caloric/protein adequacy, fasting, inadvertent output of the enteral probe and residual gastric volume were used. RESULTS 80 patients, 78.7% in emergency surgery and 21.3% in elective surgery. There was a reduction in AC and Body Mass Index (BMI) (p>0.01), especially for the emergency group. The caloric/protein adequacy was higher in the emergency group (86.7% and 81.8%). CONCLUSION The EN change was greater in the emergency group, even with better ENT adequacy. Changes in body composition are frequent in neurosurgical patients, regardless of the type of procedure.
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Affiliation(s)
| | | | - Solange Diccini
- Universidade Federal de São Paulo. São Paulo, São Paulo, Brazil
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29
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Parry SM, Chapple LAS, Mourtzakis M. Exploring the Potential Effectiveness of Combining Optimal Nutrition With Electrical Stimulation to Maintain Muscle Health in Critical Illness: A Narrative Review. Nutr Clin Pract 2018; 33:772-789. [PMID: 30358183 DOI: 10.1002/ncp.10213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Muscle wasting occurs rapidly within days of an admission to the intensive care unit (ICU). Concomitant muscle weakness and impaired physical functioning can ensue, with lasting effects well after hospital discharge. Early physical rehabilitation is a promising intervention to minimize muscle weakness and physical dysfunction. However, there is an often a delay in commencing active functional exercises (such as sitting on the edge of bed, standing and mobilizing) due to sedation, patient alertness, and impaired ability to cooperate in the initial days of ICU admission. Therefore, there is high interest in being able to intervene early through nonvolitional exercise strategies such as electrical muscle stimulation (EMS). Muscle health characterized as the composite of muscle quantity, as well as functional and metabolic integrity, may be potentially maintained when optimal nutrition therapy is provided in complement with early physical rehabilitation in critically ill patients; however, the type, dosage, and timing of these interventions are unclear. This article explores the potential role of nutrition and EMS in maintaining muscle health in critical illness. Within this article, we will evaluate fundamental concepts of muscle wasting and evaluate the effects of EMS, as well as the effects of nutrition therapy on muscle health and the clinical and functional outcomes in critically ill patients. We will also highlight current research gaps in order to advance the field forward in this important area.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Lee-Anne S Chapple
- Intensive Care Research, Royal Adelaide Hospital, South Australia, Australia
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30
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Heyland DK, Patel J, Bear D, Sacks G, Nixdorf H, Dolan J, Aloupis M, Licastro K, Jovanovic V, Rice TW, Compher C. The Effect of Higher Protein Dosing in Critically Ill Patients: A Multicenter Registry-Based Randomized Trial: The EFFORT Trial. JPEN J Parenter Enteral Nutr 2018; 43:326-334. [PMID: 30260486 DOI: 10.1002/jpen.1449] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/22/2018] [Indexed: 01/22/2023]
Abstract
Current randomized trials and observational studies evaluating higher versus lower protein doses in critically ill patients yield inconclusive results. Because of few studies and methodologic limitations, clinical guidelines suggest a wide range of protein intake based on weak evidence. Clinical equipoise about protein dosing exists. The purpose of the current manuscript is to provide the rationale and protocol for a randomized controlled trial (RCT) of 4000 critically ill patients randomly allocated to receive a higher or lower protein dose. We propose a global, volunteer-driven, registry-based RCT involving >100 intensive care units (ICUs). We will enroll mechanically ventilated patients with high nutrition risk, identified by low (≤25) or high (≥35) body mass index, moderate to severe malnutrition, frailty, sarcopenia, or when >96-hour duration of mechanical ventilation is expected. Exclusion criteria include patients who are >96 hours since initiation of mechanical ventilation, moribund, or pregnant, and where the clinician lacks clinical equipoise regarding protein dose. The intervention consists of higher (≥2.2 g/kg/d) or lower (≤1.2 g/kg/d) protein dose, achieved by enteral nutrition, parenteral nutrition, or both. The primary outcome will be 60-day mortality. Key secondary outcomes include time-to-discharge alive from hospital, ICU and hospital survival, and length of stay. As this is research based on existing medical practice, we will apply for a waiver of informed consent, where possible. The large sample size is a reflection of the small signal we expect to see in this large, pragmatic trial.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine and Department of Public Health Sciences, Queen's University, and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Danielle Bear
- Department of Critical Care, Department of Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Gordon Sacks
- Auburn University Harrison School of Pharmacy, Auburn, Alabama, USA
| | - Heidi Nixdorf
- Trillium Health Partners, Credit Valley Hospital, Mississauga, Canada
| | - Jennifer Dolan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Marianne Aloupis
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kate Licastro
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Vera Jovanovic
- Trillium Health Partners, Mississauga Hospital, Mississauga, Canada
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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31
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Abstract
PURPOSE OF REVIEW The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. RECENT FINDINGS Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. SUMMARY Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.
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Mundi MS, Patel J, McClave SA, Hurt RT. Current perspective for tube feeding in the elderly: from identifying malnutrition to providing of enteral nutrition. Clin Interv Aging 2018; 13:1353-1364. [PMID: 30122907 PMCID: PMC6080667 DOI: 10.2147/cia.s134919] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
With the number of individuals older than 65 years expected to rise significantly over the next few decades, dramatic changes to our society and health care system will need to take place to meet their needs. Age-related changes in muscle mass and body composition along with medical comorbidities including stroke, dementia, and depression place elderly adults at high risk for developing malnutrition and frailty. This loss of function and decline in muscle mass (ie, sarcopenia) can be associated with reduced mobility and ability to perform the task of daily living, placing the elderly at an increased risk for falls, fractures, and subsequent institutionalization, leading to a decline in the quality of life and increased mortality. There are a number of modifiable factors that can mitigate some of the muscle loss elderly experience especially when hospitalized. Due to this, it is paramount for providers to understand the pathophysiology behind malnutrition and sarcopenia, be able to assess risk factors for malnutrition, and provide appropriate nutrition support. The present review describes the pathophysiology of malnutrition, identifies contributing factors to this condition, discusses tools to assess nutritional status, and proposes key strategies for optimizing enteral nutrition therapy for the elderly.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA,
| | - Jayshil Patel
- Division of Pulmonary, Critical Care & Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
| | - Ryan T Hurt
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Abstract
PURPOSE OF REVIEW Protein delivery as well as exercise of critically ill in clinical practice is still a highly debated issue. Here we discuss only the most recent updates in the literature concerning protein nutrition and exercise of the critically ill. RECENT FINDINGS By lack of randomized controlled trial (RCTs) in protein nutrition we discuss four post-hoc analyses of nutrition studies and one experimental study in mice. Studies mainly confirm some insights that protein and energy effects are separate and that the trajectory of the patient in the ICU might change these effects. Exercise has been studied much more extensively with RCTs in the last year, although also here the differences between patient groups and timing of intervention might play their roles. Overall the effects of protein nutrition and exercise appear to be beneficial. However, studies into the differential effects of protein nutrition and/or exercise, and optimization of their combined use, have not been performed yet and are on the research agenda. SUMMARY Optimal protein nutrition, optimal exercise intervention as well as the optimal combination of nutrition, and exercise may help to improve long-term physical performance outcome in the critically ill patients.
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34
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Hoffer LJ. High-Protein Hypocaloric Nutrition for Non-Obese Critically Ill Patients. Nutr Clin Pract 2018; 33:325-332. [PMID: 29701916 DOI: 10.1002/ncp.10091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
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35
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Heyland DK, Stapleton R, Compher C. Should We Prescribe More Protein to Critically Ill Patients? Nutrients 2018; 10:E462. [PMID: 29642451 PMCID: PMC5946247 DOI: 10.3390/nu10040462] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/30/2022] Open
Abstract
In the context of critical illness, evidence suggests that exogenous protein/amino acid supplementation has the potential to favorably impact whole-body protein balance. Whether this translates into retention of muscle, greater muscle strength, and improved survival and physical recovery of critically ill patients remains uncertain. The purpose of this brief commentary is to provide an overview of the clinical evidence for and against increasing protein doses and to introduce two new trials that will add considerably to our evolving understanding of protein requirements in the critically ill adult patient.
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Affiliation(s)
- Daren K Heyland
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
- Department of Public Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada.
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON K7L 2V7, Canada.
| | - Renee Stapleton
- Pulmonary and Critical Care Division, University of Vermont College of Medicine, Burlington, VT 05405, USA.
| | - Charlene Compher
- Biobehavioral Research Laboratory, University of Pennsylvania, Philadelphia, PA 19104, USA.
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36
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Dos Anjos Garnes S, Bottoni A, Lasakosvitsch F, Bottoni A. Nutrition therapy: A new criterion for treatment of patients in diverse clinical and metabolic situations. Nutrition 2018; 51-52:13-19. [PMID: 29550679 DOI: 10.1016/j.nut.2017.12.009] [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: 09/26/2017] [Revised: 10/30/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE This study developed an instrument in table format to help determine the energy requirements of patients in adverse situations. The instrument allows for the weekly adjustment of nutrition therapy and energy intake, advocating a new approach to treatment based on clinical observation performed by staff specialized in individualized nutrition therapy. METHODS The table was elaborated by grouping patients according to the following criteria: criticality, chronicity, and stability of the clinical status. Energy supply was readjusted weekly to respect the cyclicity of the patient's metabolic response. RESULTS The table should be used in the following order: Obese > Elderly > Specific Clinical Situations > Chronic Diseases > Stable Clinical Situations. The protein requirements of patients with pressure ulcers or with wounds healing by secondary intention should be increased by 30% to 50%. Current patient weight should always be used, except in patients with anasarca. In these cases, the patient's last known dry weight or the ideal weight should be used. For elderly patients whose weight is not known and who cannot be weighed because of the patient's clinical condition, a body mass index of 23 should be assumed. CONCLUSION The proposed nutrition table allows for management of optimal energy and protein intake for patients in different clinical situations, while respecting the different phases of the posttraumatic metabolic response, thus leading to favorable clinical outcomes.
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37
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Kuchnia AJ, Teigen L, Nagel E, Ligthart-Melis G, Mulasi U, Weijs P, Earthman CP. Protein in the Hospital: Gaining Perspective and Moving Forward. JPEN J Parenter Enteral Nutr 2018; 42:270-278. [PMID: 29356030 DOI: 10.1002/jpen.1068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/14/2017] [Indexed: 12/15/2022]
Abstract
Provision of adequate protein is crucial for optimizing outcomes in hospitalized patients. However, the methodologies upon which current recommendations are based have limitations, and little is known about true requirements in any clinical population. In this tutorial, we aim to give clinicians an understanding of how current protein recommendations were developed, an appreciation for the limitations of these recommendations, and an overview of more sophisticated approaches that can be applied to better define protein requirements. A broader perspective of the challenges and opportunities in determining clinical protein requirements can help clinicians think critically about the individualized nutrition care they provide to their patients with the goal of administering adequate protein to optimize outcomes.
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Affiliation(s)
- Adam J Kuchnia
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Levi Teigen
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
| | - Emily Nagel
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
| | - Gerdien Ligthart-Melis
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, College Station, Texas, USA
| | - Urvashi Mulasi
- Department of Family and Consumer Sciences, California State University, Sacramento, California, USA
| | - Peter Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Carrie P Earthman
- Department of Food Science and Nutrition, University of Minnesota-Twin Cities, Minneapolis, Minnesota, USA
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38
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Weijs PJM, Dickerson RN, Heyland DK, Moore FA, Rugeles SJ, McClave SA. Experimental and Outcome-Based Approaches to Protein Requirements in the Intensive Care Unit. Nutr Clin Pract 2017; 32:77S-85S. [PMID: 28388371 DOI: 10.1177/0884533617692774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.
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Affiliation(s)
- Peter J M Weijs
- 1 Nutrition and Dietetics, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.,2 Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands.,3 Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, the Netherlands.,4 Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Roland N Dickerson
- 5 Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee, USA
| | - Daren K Heyland
- 6 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,7 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Frederick A Moore
- 8 Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Saúl J Rugeles
- 9 Department of Surgery, Pontificia Universidad Javeriana, Medical School, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Stephen A McClave
- 10 Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
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