The evolution of nutrition in critical care: how much, how soon?

Does Ileus Represent the Forgotten End Organ Failure in Critical Illness?

PURPOSE OF REVIEW

This review evaluates the current literature on ileus, impaired gastrointestinal transit (IGT), and acute gastrointestinal injury (AGI) and its impact on multiple organ dysfunction syndrome.

RECENT FINDINGS

Ileus is often under recognized in critically ill patients and is associated with significant morbidity and is potentially a marker of disease severity as seen in other organs like kidneys (ATN).

The relationship of the geriatric nutritional risk index to mortality and length of stay in elderly patients with acute respiratory failure: A retrospective cohort study

BACKGROUND

Elderly people with acute respiratory failure (ARF) have prolonged length of hospital stay (LOS) and high mortality rates. Malnutrition is negatively correlated with these LOS and mortality. However, no tools have been used to detect the risk of malnutrition and assist in designing nutritional support for these patients. The geriatric nutritional risk index (GNRI) is reported as a novel tool for evaluating the risk of malnutrition. The aim of this study is to explore the relationship of the GNRI score with mortality and LOS in elderly patients with ARF.

METHODS

Data of elderly patients diagnosed with ARF were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. A total of 1250 patients were divided into two groups based on their GNRI score: the malnutrition risk group (GNRI ≤ 98) and no risk group (GNRI > 98). The primary endpoints of this study were hospital mortality and hospital LOS.

RESULTS

The higher GNRI score was associated with lower hospital mortality and shorter hospital LOS. Odds ratio (OR) for hospital mortality of patients with nutritional risk (GNRI ≤ 98) was 1.264 (95% CI:1.067-1.497) in the adjusted model. Patients with GNRI ≤98 had longer hospital LOS (adjusted OR: 1.142, 95%CI: 1.044-1.250) compared with those with GNRI > 98. Subgroup analysis showed that higher GNRI was only significantly associated with lower hospital mortality in the patients that did not undergo mechanical ventilator (MV) treatment (adjusted OR: 0.985, 95% CI: 0.977-0.992, P < 0.01). Kaplan-Meier curve analysis showed that the 90-day survival was significantly lower in the group with nutrition risk (GNRI≤98) compared with the no risk group (GNRI > 98, p < 0.05).

CONCLUSION

These findings imply that GNRI is a useful prognostic tool in elderly patients with ARF.

Nutrition Adherence in Critically Ill Patients; How is nutritional intake within the 1st week of hospitalization affecting the patient's Outcome?

Nutritional requirements vary during a patient's stay in the Intensive Care Unit (ICU) and their calculation can be relatively complex. During ICU stay nutrition requirements are rarely met, especially during the initial days of the hospitalization. Studies have shown that poor nutrition is associated with adverse patient outcome. This study examines for correlation between poor nutrition (calories, proteins, lipids and micronutrients) during the 1^st week of ICU stay and adverse patient outcome. Nutritional adherence effect is examined on groups of patients, such as patients with high BMI that receive low nutrition and critically ill males. Regarding the latter analysis, an accuracy rate of 76.4% was achieved when classifying the critically ill males towards their outcome. The results of this work could contribute to the development of smart alarms in the ICU.

Perceived needs of patients and family caregivers regarding home-based enteral nutritional therapy in South Africa: A qualitative study

INTRODUCTION

The need for specialized care, particularly enteral nutritional therapy in community settings is now increasing with implications for both patients and primary care providers. More research is needed to identify the needs of patients and primary caregivers. The study aimed to explore the perceived support needs regarding the provision of home-based enteral nutritional therapy among critically ill adult patients and family caregivers in the KwaZulu-Natal Province of South Africa.

METHODS

A qualitative study of purposely selected adult patients on homebased enteral nutritional therapy and family caregivers was conducted in a district hospital, a community health centre, two primary health care clinics and selected households in the KwaZulu-Natal Province, South Africa. Semi-structured individual interviews were conducted between June and September 2018 and the content analysis approach was used to analyse data.

RESULTS

Two major themes and five subthemes emerged from the results of the interviews. The major themes concerned socioeconomic and psychosocial support needs related to the provision of home-based enteral nutritional therapy. Subthemes included the need for financial assistance, need for enteral nutrition products and supplementary supplies, need for infrastructure for continuity of care, and psychological support needs.

CONCLUSION

Results of this study confirm the need for developing strategies adapted to a South African context and yonder to meet patients' and family caregivers' needs with regard to nutritional services. More research on the identification of needs through monitoring and evaluation of the implementation of nutritional guidelines is needed, particularly in the district hospital and primary health care (PHC) setting.

Evidence on nutritional therapy practice guidelines and implementation in adult critically ill patients: A systematic scoping review

BACKGROUND

The rapid increase in disease-related malnutrition makes it almost impossible for healthcare practitioners and policymakers to keep up with its negative consequences. Consequently, healthcare organisations and decision-makers have called for accelerated and double-duty actions to manage the double burden of malnutrition. Guidelines standardise nutritional practices, improve nutritional status and reduce hospitalisation duration and save costs.

OBJECTIVES

A systematic scoping review of the nutritional therapy practice guidelines and implementation in critically ill adults was undertaken to identify the breadth of literature on the topic, summarise findings and identify gaps.

METHODS

A comprehensive search strategy was designed and implemented to identify eligible studies from eight databases, websites of organisations, government departments and academic platforms. Reference lists of included studies were also searched for relevant studies. We assessed the quality of included studies, completed a descriptive numerical summary and analysed them.

RESULTS

In total, 1555 titles and 101 abstracts were screened, 65 underwent full text review and 19 were retained for data extraction. Studies scored average to high on quality assessment, and a summary of characteristics of included studies is presented. Nutritional therapy practice guidelines are considered a proactive strategy for enhanced, uniform and individualised nutritional practices and factors that influence implementation were identified.

CONCLUSIONS

A gap exists between research recommendations and actual practice despite the growing interest in implementation of nutritional therapy guidelines in critical care. There is a need for more research to evaluate the practicality of available guidelines.

Evidence on nutritional therapy practice guidelines and implementation in adult critically ill patients: a scoping review protocol

BACKGROUND

Nutritional therapy practice guidelines are designed to improve nutritional practices and thus the delivery of nutritional therapy in critically ill patients. However, they are not implemented despite the strong recommendation of nutritional therapy in the management of critical illness. The aim of this study is to map evidence on nutritional therapy guidelines and their implementation in critically ill adult patients.

METHODS

Two independent reviewers will conduct a search of published scholarly and gray literature on the implementation of nutritional therapy guidelines in critically ill adults using Arksey and O'Malley's scoping review framework. The search of studies will be conducted from databases such as PubMed, Google Scholar and EBSCOhost databases, Cumulative Index for Nursing and Allied Health Literature, MEDLINE, PsychINFO, PsychARTICLES, Health Source: Consumer Edition, Health Source: Nursing/Academic Edition, PreMEDLINE, Joanna Briggs Institute, and Cochrane Databases for Systematic Reviews. We will follow a predetermined criterion to map literature and additional articles will be searched from the reference lists of included studies. The Mixed Method Appraisal Tool (MMAT) will be used for quality assessment of the included studies. Quality assessment of included studies determines the overall quality of the resultant review.

DISCUSSION

We hope to find studies on the implementation of nutritional therapy practice guidelines in adult critically ill patients and its impact on nutritional practices, patient outcomes, and health care costs. The results of this review will be disseminated through presentations in research seminars, conferences, and congresses and will also be available electronically and in print.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058864.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

This article presents 7 nutrition steps that, if not followed by the clinical staff, may be metaphorically considered as "7 deadly sins" of nutrition therapy. In this review, we suggest approaches that must be avoided or accomplished to increase compliance with the "Ten Commandments" of good nutrition practice in the intensive care setting. Multiple aggressive and simultaneous sets of therapies are implemented in the intensive care setting, which include nutrition and metabolic support as important components in these therapies. "Sins" should be remembered as a mnemonic device for nutrition standard care in the intensive care unit; this incorporates nutrition adequacy and protocol adherence.

Ancillary ICU Care in Patients with Acute Brain Insults

How to cite this article: Chhabra KD, Singh M. Ancillary ICU Care in Patients with Acute Brain Insults. Indian J Crit Care Med 2019;23(Suppl 2):S147–S150.

TARGET, PRESCRIPTION AND INFUSION OF ENTERAL NUTRITIONAL THERAPY OF CRITICAL PATIENTS IN INTENSIVE CARE UNIT

BACKGROUND

Enteral nutritional therapy (ENT) is the best route for the nutrition of critically ill patients with improved impact on the clinical treatment of such patients.

OBJECTIVE

To investigate the energy and protein supply of ENT in critically ill in-patients of an Intensive Care Unit (ICU).

METHODS

Prospective longitudinal study conducted with 82 critically ill in-patients of an ICU, receiving ENT. Anthropometric variables, laboratory tests (albumin, CRP, CRP/albumin ratio), NUTRIC-score and Nutritional Risk Screening (NRS-2002), energy and protein goals, and the inadequacies and complications of ENT were assessed. Statistical analysis was performed using the Chi-square or Fischer tests and the Wilcoxon test.

RESULTS

A total of 48.78% patients were at high nutritional risk based on NUTRIC score. In the CRP/albumin ratio, 85.37% patients presented with a high risk of complications. There was a statistically significant difference (P<0.0001) for all comparisons made between the target, prescription and ENT infusion, and 72% of the quantities prescribed for both calories and proteins was infused. It was observed that the difference between the prescription and the infusion was 14.63% (±10.81) for calories and 14.21% (±10.5) for proteins, with statistically significant difference (P<0.0001). In the relationship between prescription and infusion of calories and proteins, the only significant association was that of patients at high risk of CRP/albumin ratio, of which almost 94% received less than 80% of the energy and protein volume prescribed (P=0.0111).

CONCLUSION

The administration of ENT in severely ill patients does not meet their actual energy and protein needs. The high occurrence of infusion inadequacies, compared to prescription and to the goals set can generate a negative nutritional balance.

[Research advances in nutritional support for critically ill children]

Most critically ill children are in a state of serious stress and tend to develop malnutrition, which may reduce the body's ability to fight against diseases and repair damaged tissues and thus aggravate their conditions. Reasonable and effective nutritional support for critically ill children can improve their nutritional status and prognosis, and so it is necessary to offer nutritional support for critically ill children. This article reviews the research on nutritional support for critically ill children and the current status of clinical application. It also introduces the main methods for nutritional support, including enteral nutrition and parenteral nutrition, and elaborates on the new methods for nutritional support, such as early enteral nutrition, enteral immunonutrition, and supplementary parenteral nutrition, in order to provide a reference for nutritional support for critically ill children.

Prescribed hypocaloric nutrition support for critically-ill adults

BACKGROUND

There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive.

OBJECTIVES

To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE.

MAIN RESULTS

We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression.

AUTHORS' CONCLUSIONS

The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.

Parenteral nutrition in the critically ill

PURPOSE OF REVIEW

Feeding guidelines have recommended early, full nutritional support in critically ill patients to prevent hypercatabolism and muscle weakness. Early enteral nutrition was suggested to be superior to early parenteral nutrition. When enteral nutrition fails to meet nutritional target, it was recommended to administer supplemental parenteral nutrition, albeit with a varying starting point. Sufficient amounts of amino acids were recommended, with addition of glutamine in subgroups. Recently, several large randomized controlled trials (RCTs) have yielded important new insights. This review summarizes recent evidence with regard to the indication, timing, and dosing of parenteral nutrition in critically ill patients.

RECENT FINDINGS

One large RCT revealed no difference between early enteral nutrition and early parenteral nutrition. Two large multicenter RCTs showed harm by early supplementation of insufficient enteral nutrition with parenteral nutrition, which could be explained by feeding-induced suppression of autophagy. Several RCTs found either no benefit or harm with a higher amino acid or caloric intake, as well as harm by administration of glutamine.

SUMMARY

Although unanswered questions remain, current evidence supports accepting low macronutrient intake during the acute phase of critical illness and does not support use of early parenteral nutrition. The timing when parenteral nutrition can be initiated safely and effectively is unclear.

Autophagy and Its Implications Against Early Full Nutrition Support in Critical Illness

The timing, dose, and route of early nutrition support in critically ill patients have been highly controversial for years. Despite the association of a caloric deficit with adverse outcome, several recent large, randomized, controlled trials have demonstrated a prolongation of organ failure and increased muscle weakness with increasing doses of nutrition in the acute phase of critical illness. A potential explanation for the negative impact of early, full feeding on outcome is feeding-induced suppression of autophagy, a cellular repair process that is necessary to clear intracellular damage. Whether nutrition management in critically ill patients should be guided by its effects on autophagy is a topic of debate. Currently, however, autophagy cannot be monitored in clinical practice. Moreover, clinical management should be guided by high-quality randomized controlled trials, which currently do not support the use of early full nutrition support.

Diabetes-Specific Formulae Versus Standard Formulae as Enteral Nutrition to Treat Hyperglycemia in Critically Ill Patients: Protocol for a Randomized Controlled Feasibility Trial

Background

During critical illness, hyperglycemia is prevalent and is associated with adverse outcomes. While treating hyperglycemia with insulin reduces morbidity and mortality, it increases glycemic variability and hypoglycemia risk, both of which have been associated with an increase in mortality. Therefore, other interventions which improve glycemic control, without these complications should be explored. Nutrition forms part of standard care, but the carbohydrate load of these formulations has the potential to exacerbate hyperglycemia. Specific diabetic-formulae with a lesser proportion of carbohydrate are available, and these formulae are postulated to limit glycemic excursions and reduce patients’ requirements for exogenous insulin.

Objective

The primary outcome of this prospective, blinded, single center, randomized controlled trial is to determine whether a diabetes-specific formula reduces exogenous insulin administration. Key secondary outcomes include the feasibility of study processes as well as glycemic variability.

Methods

Critically ill patients will be eligible if insulin is administered whilst receiving exclusively liquid enteral nutrition. Participants will be randomized to receive a control formula, or a diabetes-specific, low glycemic index, low in carbohydrate study formula. Additionally, a third group of patients will receive a second diabetes-specific, low glycemic index study formula, as part of a sub-study to evaluate its effect on biomarkers. This intervention group (n=12) will form part of recruitment to a nested cohort study with blood and urine samples collected at randomization and 48 hours later for the first 12 participants in each group with a secondary objective of exploring the metabolic implications of a change in nutrition formula. Data on relevant medication and infusions, nutrition provision and glucose control will be collected to a maximum of 48 hours post randomization. Baseline patient characteristics and anthropometric measures will be recorded. A 28-day phone follow-up will explore weight and appetite changes as well as blood glucose control pre and post intensive care unit (ICU) discharge.

Results

Recruitment commenced in February 2015 with an estimated completion date for data collection by May 2018. Results are expected to be available late 2018.

Conclusions

This feasibility study of the effect of diabetes-specific formulae on the administration of insulin in critically ill patients and will inform the design of a larger, multi-center trial.

Trial Registration

Australian New Zealand Clinical Trial Registry (ANZCTR):12614000166673; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614000166673 (Archived by WebCite at http://www.webcitation.org/6xs0phrVu)

Are Predictive Energy Expenditure Equations in Ventilated Surgery Patients Accurate?

BACKGROUND:

While indirect calorimetry (IC) is the gold standard used to calculate specific calorie needs in the critically ill, predictive equations are frequently utilized at many institutions for various reasons. Prior studies suggest these equations frequently misjudge actual resting energy expenditure (REE) in medical and mixed intensive care unit (ICU) patients; however, their utility for surgical ICU (SICU) patients has not been fully evaluated. Therefore, the objective of this study was to compare the REE measured by IC with REE calculated using specific calorie goals or predictive equations for nutritional support in ventilated adult SICU patients.

MATERIALS AND METHODS:

A retrospective review of prospectively collected data was performed on all adults (n = 419, 18-91 years) mechanically ventilated for >24 hours, with an Fio₂ ≤ 60%, who met IC screening criteria. Caloric needs were estimated using Harris-Benedict equations (HBEs), and 20, 25, and 30 kcal/kg/d with actual (ABW), adjusted (ADJ), and ideal body (IBW) weights. The REE was measured using IC.

RESULTS:

The estimated REE was considered accurate when within ±10% of the measured REE by IC. The HBE, 20, 25, and 30 kcal/kg/d estimates of REE were found to be inaccurate regardless of age, gender, or weight. The HBE and 20 kcal/kg/d underestimated REE, while 25 and 30 kcal/kg/d overestimated REE. Of the methods studied, those found to most often accurately estimate REE were the HBE using ABW, which was accurate 35% of the time, and 25 kcal/kg/d ADJ, which was accurate 34% of the time. This difference was not statistically significant.

CONCLUSION:

Using HBE, 20, 25, or 30 kcal/kg/d to estimate daily caloric requirements in critically ill surgical patients is inaccurate compared to REE measured by IC. In SICU patients with nutrition requirements essential to recovery, IC measurement should be performed to guide clinicians in determining goal caloric requirements.

Peripheral vein infusions of amino acids facilitate recovery after esophagectomy for esophageal cancer: Retrospective cohort analysis

Background

To investigate the efficacy of amino acid administration via peripheral veins in addition to conventional enteral feeding following esophagectomy.

Materials and methods

Retrospective analysis of data pertaining to 33 patients with esophageal cancer who underwent radical esophagectomy and satisfied the required nutrition control. Patients were divided into the amino acid group (n = 17) and control group (n = 16). Primary outcomes were albumin (Alb) and prealbumin (PreAlb) levels, urinary 3-methylhistidine/creatinine (3-MeHis/Cre) ratios, nitrogen balance, and weight; postoperative complications were noted as secondary outcomes.

Results

Alb levels were significantly higher in the amino acid group on postoperative day (POD)-14 (3.4 ± 0.3 vs. 3.1 ± 0.4 mg/dL in the control group, p = 0.018) and at 1 month after surgery (3.8 ± 0.4 vs. 3.5 ± 0.3 mg/dL, p = 0.045). No significant differences were observed in PreAlb and urinary 3-MeHis/Cre rates between the treatment groups. Body weights at 3 months postoperatively were decreased by 6% and 3% in the control and amino acid groups, respectively.

Conclusion

Peripheral venous administration of amino acids soon after surgical stress is an effective method for nutritional control.

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Radical resection for esophageal cancer is a highly invasive procedure.

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Enteral feeding has been used in postoperative period for esophagectomy.

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Peripheral vein infusion of amino acids is effective for post esophagectomy.

The dilemma of protein delivery in the intensive care unit

OBJECTIVE

Optimal protein delivery in the intensive care unit (ICU) may offer a significant mortality benefit, whereas energy overfeeding leads to worse outcomes. The aim of the present study was to assess actual protein versus energy delivery in a multidisciplinary adult ICU.

METHODS

We conducted a retrospective review of ICU charts to determine total protein delivery and energy delivery, inclusive of non-nutritional energy sources (NNES), from admission until a maximum of 7 d. The outcome variables were protein and energy delivery relative to targets and cumulative protein and energy balance.

RESULTS

We included 71 patients (49% male), with a mean age of 49.2 ± 17.1 y. Of the patients, 68% were medical and 32% surgical. Nutrition therapy was initiated within 14.5 ± 14.1 h. The majority (80%) received enteral nutrition (EN). Median protein delivery and energy delivery were 75 g/d (1.1 g·kg·d(-1), range 21-135 g/d) and 1642 kcal/d (26 kcal·kg·d(-1), range 740-2619 kcal/d), meeting 89% (range 24-103%) and 100% (range 39-133%) of target, respectively. NNES, mostly from carbohydrate-containing intravenous fluids, contributed 8% (range 0-29%) to total energy delivery (133 kcal/d, range 0-561). Protein and energy underfeeding occurred in 51% and 27% of cases, respectively. Only 59% of those with an adequate energy delivery (90-110% of target) achieved an adequate protein delivery. A significant negative correlation was found between cumulative protein and energy balance and time to initiation of NT (protein: R = -0.33, P = 0.006; energy: R = -0.28, P = 0.017).

CONCLUSIONS

Early initiation of EN with currently available energy-rich formulas is insufficient to achieve adequate protein delivery. NNES add to total energy delivery. Novel EN formulas with a lower nonprotein energy-to-nitrogen ratio may help to optimize protein delivery without the harmful effects of energy overfeeding.

Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology

Over the last 10 years we have significantly reduced hospital mortality from sepsis and critical illness. However, the evidence reveals that over the same period we have tripled the number of patients being sent to rehabilitation settings. Further, given that as many as half of the deaths in the first year following ICU admission occur post ICU discharge, it is unclear how many of these patients ever returned home. For those who do survive, the latest data indicate that 50-70% of ICU "survivors" will suffer cognitive impairment and 60-80% of "survivors" will suffer functional impairment or ICU-acquired weakness (ICU-AW). These observations demand that we as intensive care providers ask the following questions: "Are we creating survivors ... or are we creating victims?" and "Do we accomplish 'Pyrrhic Victories' in the ICU?" Interventions to address ICU-AW must have a renewed focus on optimal nutrition, anabolic/anticatabolic strategies, and in the future employ the personalized muscle and exercise evaluation techniques utilized by elite athletes to optimize performance. Specifically, strategies must include optimal protein delivery (1.2-2.0 g/kg/day), as an athlete would routinely employ. However, as is clear in elite sports performance, optimal nutrition is fundamental but alone is often not enough. We know burn patients can remain catabolic for 2 years post burn; thus, anticatabolic agents (i.e., beta-blockers) and anabolic agents (i.e., oxandrolone) will probably also be essential. In the near future, evaluation techniques such as assessing lean body mass at the bedside using ultrasound to determine nutritional status and ultrasound-measured muscle glycogen as a marker of muscle injury and recovery could be utilized to help find the transition from the acute phase of critical illness to the recovery phase. Finally, exercise physiology testing that evaluates muscle substrate utilization during exercise can be used to diagnose muscle mitochondrial dysfunction and to guide a personalized ideal heart rate, assisting in recovery of muscle mitochondrial function and functional endurance post ICU. In the end, future ICU-AW research must focus on using a combination of modern performance-enhancing nutrition, anticatabolic/anabolic interventions, and muscle/exercise testing so we can begin to create more "survivors" and fewer victims post ICU care.

Early oral refeeding based on hunger in moderate and severe acute pancreatitis: a prospective controlled, randomized clinical trial

OBJECTIVE

Early enteral nutrition is beneficial for acute pancreatitis (AP), but the optimal timing and criteria remain unclear. The aim of this study was to explore the feasibility and safety of early oral refeeding (EORF) based on hunger in patients with moderate or severe AP.

METHODS

In a prospective, single-center, controlled, randomized clinical trial (ChiCTR-TRC-12002994), eligible patients with moderate or severe AP were randomized to either EORF or conventional oral refeeding (CORF). Patients in the EORF group restarted an oral diet when they felt hungry, regardless of laboratory parameters. Those in the CORF group restarted an oral diet only when clinical and laboratory symptoms had resolved. Clinical outcomes were compared between the two groups.

RESULTS

In all, 146 eligible patients with moderate or severe AP were included and randomized to the EORF (n = 70) or CORF (n = 76) group. There were eight dropouts after randomization (three in EORF group; five in CORF group). The groups had similar baseline characteristics. The total length of hospitalization (13.7 ± 5.4 d versus 15.7 ± 6.2 d; P = 0.0398) and duration of fasting (8.3 ± 3.9 d versus 10.5 ± 5.1 d; P = 0.0047) were shorter in the EORF group than in the CORF group. There was no difference in the number of adverse events or complications between the two groups. The mean blood glucose level after oral refeeding was higher in the EORF group than in the CORF group (P = 0.0030).

CONCLUSIONS

This controlled, randomized clinical trial confirmed the effectiveness and feasibility of EORF based on hunger in patients with moderate or severe AP. EORF could shorten the length of hospitalization in patients with moderate or severe AP.

Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up

RATIONALE

We hypothesized that providing patients with acute lung injury two different protein/calorie nutritional strategies in the intensive care unit may affect longer-term physical and cognitive performance.

OBJECTIVES

To assess physical and cognitive performance 6 and 12 months after acute lung injury, and to evaluate the effect of trophic versus full enteral feeding, provided for the first 6 days of mechanical ventilation, on 6-minute-walk distance, cognitive impairment, and secondary outcomes.

METHODS

A prospective, longitudinal ancillary study of the ARDS Network EDEN trial evaluating 174 consecutive survivors from 5 of 12 centers. Blinded assessments of patients' arm anthropometrics, strength, pulmonary function, 6-minute-walk distance, and cognitive status (executive function, language, memory, verbal reasoning/concept formation, and attention) were performed.

MEASUREMENTS AND MAIN RESULTS

At 6 and 12 months, respectively, the mean (SD) percent predicted for 6-minute-walk distance was 64% (22%) and 66% (25%) (P = 0.011 for difference between assessments), and 36 and 25% of survivors had cognitive impairment (P = 0.001). Patients performed below predicted values for secondary physical tests with small improvement from 6 to 12 months. There was no significant effect of initial trophic versus full feeding for the first 6 days after randomization on survivors' percent predicted for 6-minute-walk distance, cognitive impairment status, and all secondary outcomes.

CONCLUSIONS

EDEN trial survivors performed below predicted values for physical and cognitive performance at 6 and 12 months, with some improvement over time. Initial trophic versus full enteral feeding for the first 6 days after randomization did not affect physical and cognitive performance.