Intensive care unit nutrition -- nonsense or neglect?

Key Aspects in Nutritional Management of COVID-19 Patients

This review deals with the relationship among nutrition, the immune system, and coronavirus disease 2019 (COVID-19). The influence of nutrients and bioactive molecules present in foodstuffs on immune system activity, the influence of COVID-19 on the nutritional status of the patients, and the dietary recommendations for hospitalized patients are addressed. Deficient nutritional status is probably due to anorexia, nausea, vomiting, diarrhea, hypoalbuminemia, hypermetabolism, and excessive nitrogen loss. There is limited knowledge regarding the nutritional support during hospital stay of COVID-19 patients. However, nutritional therapy appears as first-line treatment and should be implemented into standard practice. Optimal intake of all nutrients, mainly those playing crucial roles in immune system, should be assured through a diverse and well-balanced diet. Nevertheless, in order to reduce the risk and consequences of infections, the intakes for some micronutrients may exceed the recommended dietary allowances since infections and other stressors can reduce micronutrient status. In the case of critically ill patients, recently published guidelines are available for their nutritional management. Further, several natural bioactive compounds interact with the angiotensin-converting enzyme 2 (ACE2) receptor, the gateway for severe acute respiratory syndrome (SARS) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Natural bioactive compounds can also reduce the inflammatory response induced by SARS-CoV-2. These compounds are potential beneficial tools in the nutritional management of COVID-19 patients.

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.

Immunonutrition in Critical Illness: What Is the Role?

Acute illness-associated malnutrition leads to muscle wasting, delayed wound healing, failure to wean from ventilator support, and possibly higher rates of infection and longer hospital stays unless appropriate metabolic support is provided in the form of nutrition therapy. Agreement is still lacking about the value of individual immune-modulating substrates for specific patient populations. However, it has long been agreed that there are 3 primary targets for these substrates: 1) mucosal barrier function, 2) cellular defense function, and 3) local and systemic inflammation. These targets guide the multitude of interventions necessary to stabilize and treat the hypercatabolic intensive care unit patient, including specialized nutrition therapy. The paradigm shift that occurred 30 years ago created a unique role for nutrition as an agent to support host defense mechanisms and prevent infectious complications in the critically ill patient. This overview of immunonutrition will discuss the evidence for its role in critical illness today.

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis

Introduction

Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis.

Methods

We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis.

Results

Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients.

Conclusions

Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.