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Jutba AS, Kamel A, Nguyen Q, Patel K, Cash J, Popp J, Mazirka P, Roberson L, Allen A, Omalay Q, Cochran A. Impact of an enteral nutrition protocol in critically ill patients with burn injuries. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2024; 14:58-64. [PMID: 39022443 PMCID: PMC11249807 DOI: 10.62347/ygqw7641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVES The objective of this study is to characterize the University of Florida (UF) Health Shands Burn Centers enteral nutrition protocol as it relates to total protein intake and clinical outcomes. METHODS This retrospective chart review study included 99 adult patients admitted to the UF Health Shands Burn Center from January 2012 through August 2016 with burns of twenty percent or greater TBSA and required enteral nutrition supplementation. RESULTS Patients received an average of 137.8 g or 2.03 g/kg protein daily. Fifteen percent of patients experienced graft loss. The median length of stay was 35 days. Seventy-six percent survived to hospital discharge. There was no significant association between total protein intake and incidence of severe diarrhea (P=0.132). CONCLUSION The institutions protocol achieved high protein administration while still being consistent with recommendations from the American Society of Enteral and Parenteral Nutrition (ASPEN).
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Affiliation(s)
- Ada Selina Jutba
- Department of Pharmacy, University of Florida Health Shands HospitalGainesville, FL, USA
- Department of Pharmacy, Memorial Hermann Memorial City Medical CenterHouston, TX, USA
| | - Amir Kamel
- Department of Pharmacy, University of Florida Health Shands HospitalGainesville, FL, USA
| | - Quynhnhu Nguyen
- University of Florida College of PharmacyGainesville, FL, USA
| | - Kunal Patel
- University of Florida College of PharmacyGainesville, FL, USA
| | - Julie Cash
- Presbyterian College School of PharmacyClinton, SC, USA
| | - Janet Popp
- The Burn Center, University of Florida Shands HospitalGainesville, FL, USA
| | - Pavel Mazirka
- University of Florida College of MedicineGainesville, FL, USA
| | - Laura Roberson
- The Burn Center, University of Florida Shands HospitalGainesville, FL, USA
| | - Ashlee Allen
- The Burn Center, University of Florida Shands HospitalGainesville, FL, USA
| | - Quennie Omalay
- The Burn Center, University of Florida Shands HospitalGainesville, FL, USA
| | - Amalia Cochran
- University of Florida College of MedicineGainesville, FL, USA
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Lew CCH, Lee ZY, Day AG, Jiang X, Bear D, Jensen GL, Ng PY, Tweel L, Parillo A, Heyland DK, Compher C. The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients: A Post Hoc Analysis of the EFFORT Protein Randomized Trial. Chest 2024; 165:1380-1391. [PMID: 38354904 DOI: 10.1016/j.chest.2024.02.008] [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: 12/12/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Preexisting malnutrition in critically ill patients is associated with adverse clinical outcomes. Malnutrition can be diagnosed with the Global Leadership Initiative on Malnutrition using parameters such as weight loss, muscle wasting, and BMI. International critical care nutrition guidelines recommend high protein treatment to improve clinical outcomes in critically ill patients diagnosed with preexisting malnutrition. However, this recommendation is based on expert opinion. RESEARCH QUESTION In critically ill patients, what is the association between preexisting malnutrition and time to discharge alive (TTDA), and does high protein treatment modify this association? STUDY DESIGN AND METHODS This multicenter randomized controlled trial involving 16 countries was designed to investigate the effects of high vs usual protein treatment in 1,301 critically ill patients. The primary outcome was TTDA. Multivariable regression was used to identify if preexisting malnutrition was associated with TTDA and if protein delivery modified their association. RESULTS The prevalence of preexisting malnutrition was 43.8%, and the cumulative incidence of live hospital discharge by day 60 was 41.2% vs 52.9% in the groups with and without preexisting malnutrition, respectively. The average protein delivery in the high vs usual treatment groups was 1.6 g/kg per day vs 0.9 g/kg per day. Preexisting malnutrition was independently associated with slower TTDA (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20). INTERPRETATION Malnutrition was associated with slower TTDA, but high protein treatment did not modify the association. These findings challenge current international critical care nutrition guidelines. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03160547; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore; Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Danielle Bear
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Gordon L Jensen
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Pauline Y Ng
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Lauren Tweel
- Clinical and Preventive Nutrition Sciences, Rutgers University, School of Health Professions, New Brunswick, NJ; Foothills Medical Centre, Calgary, AB, Canada
| | - Angela Parillo
- Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania, School of Nursing, Philadelphia, PA.
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Blaauw L, Schoonees A, Robertson N, Visser J. The impact of guideline recommended protein intake on mortality and length of intensive care unit and hospital stay in critically ill adults: A systematic review. Clin Nutr ESPEN 2024; 61:356-368. [PMID: 38777455 DOI: 10.1016/j.clnesp.2024.04.003] [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: 12/04/2023] [Revised: 03/13/2024] [Accepted: 04/01/2024] [Indexed: 05/25/2024]
Abstract
International guidelines recommend a target protein intake of ≥1.2 g/kg/day to all critically ill patients for optimal outcomes. There are however various conflicting data related to this recommendation. The primary objective of this review was to compare a protein intake group (≥1.2 g/kg/day) with a lower protein intake group (<1.2 g/kg/day) in critically ill adult patients on mortality, length of intensive care unit (ICU) and hospital stay. Secondly, the effect of protein intake on length of mechanical ventilation, adverse nutrition-related events and muscle mass and strength parameters were investigated. Sixteen randomised controlled trials (RCTs) of adult patients admitted to an intensive or high care unit and receiving nutrition support in the form of enteral- and/or parenteral nutrition were selected against prespecified eligibility criteria. Two independent reviewers extracted relevant data and assessed the risk of bias of the included studies. Review Manager 5.4.1 was used to analyse data and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) was used to evaluate the certainty of the evidence. The higher protein group, when compared to the lower protein group, probably results in little to no difference in mortality (risk ratio [RR] 1.01; 95% confidence interval [CI]: 0.89 to 1.14; moderate-certainty evidence); with a probable slight increase in length of ICU stay (mean difference [MD] 0.33; 95% CI -0.57 to 1.23; moderate-certainty) and length of hospital stay (MD 1.72; 95% CI -0.58 to 4.01; moderate-certainty evidence), on average. For secondary outcomes, it was found that the higher protein group probably does not reduce the length of mechanical ventilation (MD 0.08; 95% CI -0.38 to 0.53; moderate-certainty evidence). Higher protein group probably reduces the occurrence of diarrhoea and high gastric residual volume and may reduce the occurrence of constipation. It may also increase nitrogen balance (MD 3.66; 95% CI 1.81 to 5.51; low-certainty evidence). Importantly, there does not seem to be harm associated with the higher protein group, though it should be mentioned that for many of the adverse events in this study, the certainty of evidence was low or very low.
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Affiliation(s)
- Liezel Blaauw
- Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa.
| | - Anel Schoonees
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Nina Robertson
- Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Janicke Visser
- Division of Human Nutrition, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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4
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Qin Y, Huang J, Ping X, Zheng H, Zhang K, Xu X, Yu J. No benefit of higher protein dosing in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. PeerJ 2024; 12:e17433. [PMID: 38799065 PMCID: PMC11122048 DOI: 10.7717/peerj.17433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose The optimal range of protein dosage and effect of high-dose protein on critically ill patients remain controversial. We conducted a meta-analysis to compare higher and lower doses of protein supplementation for nutritional support in critically ill patients. Methods We searched the PubMed, Embase, Scopus, and Cochrane Library databases for randomized controlled trials that compared higher (≥1.2 g/kg per day) versus lower (<1.2 g/kg per day) doses of protein supplementation among critically ill adult patients. This search spanned from the inception of relevant databases to November 20, 2023. Our primary endpoint of interest was overall mortality, while secondary endpoints included length of stay in the intensive care unit, length of hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury. Results Seventeen studies including 2,965 critically ill patients were included in our meta-analysis. The pooled analyses showed no significant difference in overall mortality (RR 1.03, 95%CI [0.92-1.15], P = 0.65, I2 = 0%), length of intensive care unit stay (MD 0.19, 95%CI [-0.67 to 1.04], P = 0.66, I2 = 25%), length of hospital stay (MD 0.73, 95%CI [-1.59 to 3.04], P = 0.54, I2 = 27%), duration of mechanical ventilation (MD -0.14, 95%CI [-0.83 to 0.54], P = 0.68, I2 = 8%), and incidence of acute kidney injury (RR 1.11, 95%CI [0.87-1.41], P = 0.38, I2 = 0%) between critically ill patients receiving higher or lower doses of protein supplementation. Conclusions For critically ill patients, the protein supplementation dose had no significant effect on clinical outcomes, including overall mortality, length of intensive care unit and hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury.
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Affiliation(s)
- Yonggen Qin
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoya Xu
- Department of General Surgery, Lishui People’s Hospital, Lishui, China
| | - Jiuqing Yu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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5
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Correia MITD, Rosenfeld RS. Nutritional management during critical illness in those with previous obesity surgery. Curr Opin Clin Nutr Metab Care 2024; 27:192-199. [PMID: 38190340 DOI: 10.1097/mco.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW The prevalence of overweight and obesity in our society is a pressing concern that has demanded immediate attention. Traditional treatments have proven ineffective for many individuals, leading to a surge in bariatric surgery as a last resort. While the rate of early and late postoperative complications may be low, when they occur, they place these patients at higher risk of requiring intensive care treatment. Therefore, it is our aim to discuss the nutritional care of these individuals. RECENT FINDINGS Nutritional management of critically ill postbariatric surgical patients is related to the difficulty of providing an adequate nutritional assessment, calculating the macro and micronutrient requirements, choosing the right therapy, and defining the timely moment to initiate it. The anatomic changes related to the bariatric operation pose a high risk for a nonfunctional gastrointestinal tract both in the early postoperative and late postoperative. Therefore, the route of nutrition will greatly rely on the absorptive capacity, as well as on the nutritional status, with parenteral nutrition being an early option, especially for those with high critical care severity scores. Also, these patients are known to have an altered microbiota which may influence the absorptive capacity. Immunonutrition, prebiotics, probiotics, and symbiotics may represent potential options, but there is currently little support for 'one size fits all'. SUMMARY The nutritional care of critically ill patients postbariatric surgery is a complex and nuanced process requiring a multifaceted precision approach. The distinct nutritional challenges of early and late postoperative patients necessitate a thorough nutritional assessment and a highly individualized nutritional care plan.
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Wang Y, Li Y, Li Y, Li H, Zhang D. Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding. Nutrition 2024; 117:112255. [PMID: 37897987 DOI: 10.1016/j.nut.2023.112255] [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: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023]
Abstract
Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.
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Affiliation(s)
- Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yanhua Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Hongxiang Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
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7
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van Ruijven IM, Abma J, Brunsveld-Reinders AH, Stapel SN, van Etten-Jamaludin F, Boirie Y, Barazzoni R, Weijs PJM. High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta-analyses. Clin Nutr 2023; 42:2395-2403. [PMID: 37862825 DOI: 10.1016/j.clnu.2023.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature. METHODS We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies. RESULTS A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass. CONCLUSION High protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.
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Affiliation(s)
- Isabel M van Ruijven
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands.
| | - José Abma
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anja H Brunsveld-Reinders
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Department of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands
| | - Sandra N Stapel
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Faridi van Etten-Jamaludin
- Amsterdam UMC Location University of Amsterdam, Medical Library AMC, Meibergdreef 9, Amsterdam, the Netherlands
| | - Yves Boirie
- University of Clermont Auvergne, INRAE, CRNH, Clinical Nutrition Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Peter J M Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
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8
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Unoki T, Hayashida K, Kawai Y, Taito S, Ando M, Iida Y, Kasai F, Kawasaki T, Kozu R, Kondo Y, Saitoh M, Sakuramoto H, Sasaki N, Saura R, Nakamura K, Ouchi A, Okamoto S, Okamura M, Kuribara T, Kuriyama A, Matsuishi Y, Yamamoto N, Yoshihiro S, Yasaka T, Abe R, Iitsuka T, Inoue H, Uchiyama Y, Endo S, Okura K, Ota K, Otsuka T, Okada D, Obata K, Katayama Y, Kaneda N, Kitayama M, Kina S, Kusaba R, Kuwabara M, Sasanuma N, Takahashi M, Takayama C, Tashiro N, Tatsuno J, Tamura T, Tamoto M, Tsuchiya A, Tsutsumi Y, Nagato T, Narita C, Nawa T, Nonoyama T, Hanada M, Hirakawa K, Makino A, Masaki H, Matsuki R, Matsushima S, Matsuda W, Miyagishima S, Moromizato M, Yanagi N, Yamauchi K, Yamashita Y, Yamamoto N, Liu K, Wakabayashi Y, Watanabe S, Yonekura H, Nakanishi N, Takahashi T, Nishida O. Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023). J Intensive Care 2023; 11:47. [PMID: 37932849 PMCID: PMC10629099 DOI: 10.1186/s40560-023-00697-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/24/2023] [Indexed: 11/08/2023] Open
Abstract
Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.
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Affiliation(s)
- Takeshi Unoki
- Department Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan.
| | - Kei Hayashida
- Department of Emergency Medicine, South Shore University Hospital, Northwell Health, Bay Shore, NY, USA
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Shunsuke Taito
- Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Morihide Ando
- Department of Pulmonary Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yuki Iida
- Faculty of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Fumihito Kasai
- Department of Rehabilitation Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Masakazu Saitoh
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Hideaki Sakuramoto
- Department of Critical Care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Japan
| | - Nobuyuki Sasaki
- Department of Rehabilitation Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Ryuichi Saura
- Department of Rehabilitation Medicine, Division of Comprehensive Medicine, Osaka Medical and Pharmaceutical University School of Medicine, Takatsuki, Japan
| | - Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Akira Ouchi
- Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Saiko Okamoto
- Department of Nursing, Hitachi General Hospital, Hitachi, Japan
| | - Masatsugu Okamura
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tomoki Kuribara
- Department Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yujiro Matsuishi
- School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Norimasa Yamamoto
- Department of Nursing, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Shodai Yoshihiro
- Department of Pharmaceutical Services, Hiroshima University Hospital, Hiroshima, Japan
| | - Taisuke Yasaka
- Global Nursing Research Center, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Ryo Abe
- Department of Rehabilitation, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takahito Iitsuka
- Department of Rehabilitation, Amagasaki Daimotsu Rehabilitation Hospital, Amagasaki, Japan
| | - Hiroyasu Inoue
- Department of Rehabilitation, Showa University School of Nursing and Rehabilitation Sciences, Yokohama, Japan
| | - Yuki Uchiyama
- Department of Rehabilitation Medicine, School of Medicine, Hyogo Medical University, Nishinomiya, Japan
| | - Satoshi Endo
- Rehabilitation Center, Amayama Hospital, Matsuyama, Japan
| | - Kazuki Okura
- Division of Rehabilitation, Akita University Hospital, Akita, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahisa Otsuka
- Department of Rehabilitation Medicine, Okayama University Hospital, Okayama, Japan
| | - Daisuke Okada
- Department of Rehabilitation, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kengo Obata
- Department of Rehabilitation, Japanese Red Cross Okayama Hospital, Okayama, Japan
| | - Yukiko Katayama
- Department of Nursing, Sakakibara Heart Institute, Fuchu, Japan
| | - Naoki Kaneda
- Rehabilitation Division, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Mio Kitayama
- Nursing Department, Kanazawa Medical University Hospital, Uchinada, Japan
| | - Shunsuke Kina
- Department of Rehabilitation, Nakagami Hospital, Okinawa, Japan
| | - Ryuichi Kusaba
- Department of Rehabilitation Medicine, Kyushu University Hospital, Fukuoka, Japan
| | | | - Naoki Sasanuma
- Department of Rehabilitation, Hyogo Medical University Hospital, Nishinomiya, Japan
| | | | | | - Naonori Tashiro
- Rehabilitation Center, Showa University Hospital, Tokyo, Japan
| | - Junko Tatsuno
- Department of Nursing, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Takahiko Tamura
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Nankoku, Japan
| | - Mitsuhiro Tamoto
- Department of Nursing, Kyoto University Hospital, Kyoto, Kyoto, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Yusuke Tsutsumi
- Department of Emergency Medicine, National Hospital Organization Mito Medical Center, Mito, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine and Infectious Diseases, JCHO Tokyo Yamate Medical Center, Tokyo, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomohiro Nawa
- Department of Pediatric Cardiology, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Tadayoshi Nonoyama
- Department of Rehabilitation, University of Fukui Hospital, Fukui, Japan
| | - Masatoshi Hanada
- Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kotaro Hirakawa
- Department of Rehabilitation, Sakakibara Heart Institute, Fuchu, Japan
| | - Akiko Makino
- School of Nursing, St. Luke's International University, Tokyo, Japan
| | - Hirotaka Masaki
- Department of Nursing, Nagoya University Hospital, Nagoya, Japan
| | - Ryosuke Matsuki
- Department of Rehabilitation, Kansai Electric Power Hospital, Osaka, Japan
| | | | - Wataru Matsuda
- Department of Emergency Medicine & Critical Care, Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Japan
| | - Saori Miyagishima
- Division of Rehabilitation, Sapporo Medical University Hospital, Hokkaido, Japan
| | - Masaru Moromizato
- Department of Nursing, Chubu Tokushukai Hospital, Kitanakagusuku, Japan
| | - Naoya Yanagi
- Department of Rehabilitation, Kitasato University Medical Center, Kitamoto, Japan
| | - Kota Yamauchi
- Department of Rehabilitation, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Yuhei Yamashita
- Division of Rehabilitation Medicine, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Natsuhiro Yamamoto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University School of Medicine, Yokohama, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), Tokyo, Japan
| | - Yuki Wakabayashi
- Department of Nursing, Kobe City Center General Hospital, Kobe, Japan
| | - Shinichi Watanabe
- Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, Gifu, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tetsuya Takahashi
- Department of Physical Therapy, Faculty of Health Science, Juntendo University, Tokyo, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan
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9
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Barth I, Beumeler LFE, Nahar-van Venrooij L, van Dijk O, Buter H, Boerma EC. The effect of protein provision and exercise therapy on patient-reported and clinical outcomes in intensive care unit survivors: A systematic review. J Hum Nutr Diet 2023; 36:1727-1740. [PMID: 37211649 DOI: 10.1111/jhn.13188] [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: 10/20/2022] [Accepted: 05/18/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Intensive care unit (ICU) survivors deal with long-term health problems, which negatively affect their quality of life (QoL). Nutritional and exercise intervention could prevent the decline of muscle mass and physical functioning which occurs during critical illness. Despite the growing amount of research, robust evidence is lacking. METHODS For this systematic review, Embase, PubMed and Cochrane Central Register of Controlled Trials databases were searched. The effect of protein provision (PP) or combined protein and exercise therapy (CPE) during or after ICU admission on QoL, physical functioning, muscle health, protein/energy intake and mortality was assessed compared to standard care. RESULTS Four thousand nine hundred and fifty-seven records were identified. After screening, data were extracted for 15 articles (9 randomised controlled trials and 6 non-randomised studies). Two studies reported improvements in muscle mass, of which one found higher independency in activities of daily living. No significant effect was found on QoL. Overall, protein targets were seldom met and often below recommendations. CONCLUSION Evidence for the effect of PP or CPE on patient-reported outcomes in ICU survivors is limited due to study heterogeneity and lack of high-quality studies. Future research and clinical practice should focus on adequate protein delivery with exercise interventions to improve long-term outcomes.
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Affiliation(s)
- Iris Barth
- Department of Dietetics, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Lise F E Beumeler
- Campus Fryslân, University of Groningen, Leeuwarden, The Netherlands
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Lenny Nahar-van Venrooij
- Department of Data Science and Epidemiology, University Medical Centre Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
- Jeroen Bosch Academy Research, Jeroen Bosch Hospital, Hertogenbosch, The Netherlands
| | - Olga van Dijk
- Knowledge and Information Centre, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Hanneke Buter
- Department of Data Science and Epidemiology, University Medical Centre Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Department of Data Science and Epidemiology, University Medical Centre Amsterdam and University of Amsterdam, Amsterdam, The Netherlands
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Yang Q, Lyu S, Xu M, Li S, Du Z, Liu X, Shang X, Yu Z, Liu J, Zhang T. Potential Benefits of Egg White Proteins and Their Derived Peptides in the Regulation of the Intestinal Barrier and Gut Microbiota: A Comprehensive Review. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2023; 71:13168-13180. [PMID: 37639307 DOI: 10.1021/acs.jafc.3c03230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Impaired intestinal barrier function can impede the digestion and absorption of nutrients and cause a range of metabolic disorders, which are the main causes of intestinal disease. Evidence suggests that proper dietary protein intake can prevent and alleviate intestinal diseases. Egg white protein (EWP) has received considerable attention, because of its high protein digestibility and rich amino acid composition. Furthermore, bioactive peptides may have an increased repair effect due to their high degradation efficiency in the gut. In this study, we aimed to review the effects of EWP and its bioactive peptides on intestinal structural repair. The potential modulation mechanisms by which EWP and their peptides regulate the gut microbiota and intestinal barrier can be summarized as follows: (1) restoring the structure of the intestinal barrier to its intact form, (2) enhancing the intestinal immune system and alleviating the inflammatory response and oxidative damage, and (3) increasing the relative abundance of beneficial bacteria and metabolites. Further in-depth analysis of the coregulation of multiple signaling pathways by EWP is required, and the combined effects of these multiple mechanisms requires further evaluation in experimental models. Human trials can be considered to understand new directions for development.
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Affiliation(s)
- Qi Yang
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Siwen Lyu
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Menglei Xu
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Shengrao Li
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Zhiyang Du
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Xuanting Liu
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Xiaomin Shang
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Zhipeng Yu
- School of Food Science and Engineering, Hainan University, 570228 Haikou, China
| | - Jingbo Liu
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
| | - Ting Zhang
- Jilin Provincial Key Laboratory of Nutrition and Functional Food, Jilin University, 130062 Changchun, China
- College of Food Science and Engineering, Jilin University, 130062 Changchun, China
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11
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Zaragoza-García I, Arias-Rivera S, Frade-Mera MJ, Martí JD, Gallart E, San José-Arribas A, Velasco-Sanz TR, Blazquez-Martínez E, Raurell-Torredà M. Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study. PLoS One 2023; 18:e0286598. [PMID: 37285356 DOI: 10.1371/journal.pone.0286598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVE To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours. METHODS A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN. RESULTS 319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7. CONCLUSIONS The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset. RELEVANCE TO CLINICAL PRACTICE Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.
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Affiliation(s)
- Ignacio Zaragoza-García
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Invecuid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Susana Arias-Rivera
- University Hospital of Getafe, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Getafe, Spain
| | - María Jesús Frade-Mera
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Department of Critical Care, 12 Octubre University Hospital, Madrid, Spain
| | | | - Elisabet Gallart
- Department of Critical Care, Vall Hebron University Hospital, Barcelona, Spain
| | - Alicia San José-Arribas
- Escola Universitaria d'Infermeria Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Tamara Raquel Velasco-Sanz
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Department of Critical Care, San Carlos University Hospital, Madrid, Spain
| | | | - Marta Raurell-Torredà
- Department d'Infermeria Fonamental i medicoquirúrgica, Facultat d'Infermeria, Universitat de Barcelona, Barcelona, Spain
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12
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Sepsis-Associated Muscle Wasting: A Comprehensive Review from Bench to Bedside. Int J Mol Sci 2023; 24:ijms24055040. [PMID: 36902469 PMCID: PMC10003568 DOI: 10.3390/ijms24055040] [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: 01/15/2023] [Revised: 02/21/2023] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
Sepsis-associated muscle wasting (SAMW) is characterized by decreased muscle mass, reduced muscle fiber size, and decreased muscle strength, resulting in persistent physical disability accompanied by sepsis. Systemic inflammatory cytokines are the main cause of SAMW, which occurs in 40-70% of patients with sepsis. The pathways associated with the ubiquitin-proteasome and autophagy systems are particularly activated in the muscle tissues during sepsis and may lead to muscle wasting. Additionally, expression of muscle atrophy-related genes Atrogin-1 and MuRF-1 are seemingly increased via the ubiquitin-proteasome pathway. In clinical settings, electrical muscular stimulation, physiotherapy, early mobilization, and nutritional support are used for patients with sepsis to prevent or treat SAMW. However, there are no pharmacological treatments for SAMW, and the underlying mechanisms are still unknown. Therefore, research is urgently required in this field.
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Uyar E, Yagmurdur H, Yamanyar S, Güdek Y, Dal MC, Cosar A. The effect of protein enriched nutrition on diaphragm function in mechanically ventilated patients. NUTR CLIN METAB 2023. [DOI: 10.1016/j.nupar.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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14
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Ochoa Gautier JB, Berger A, Hussein R, Huhmann MB. Safety of increasing protein delivery with an enteral nutrition formula containing very high protein (VHP) and lower carbohydrate concentrations compared to conventional standard (SF) and high protein (HP) formulas. Clin Nutr 2022; 41:2833-2842. [PMID: 36402010 DOI: 10.1016/j.clnu.2022.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND & AIMS Studies demonstrate that caloric restriction in the first seven days in the ICU is safe. The amount of protein that should be delivered, however, is still unclear with clinical trials suggesting mixed results. Despite some capacity to customize the delivery of protein using supplemental modules, protein delivered is best determined by the concentration of protein contained in enteral formula (EF) ordered. This fact provides an opportunity to explore the potential clinical effects of protein delivery and lower carbohydrate intake on clinical outcomes compared with conventional enteral formulas. METHODS Retrospective analysis of clinical outcomes according to the amount of protein delivered in critically ill patients admitted to intensive care units at Geisinger Health System. RESULTS 2000 encounters (1899 patients) in patients on enteral nutrition were divided into three groups receiving EF with either ≤20% protein (standard formula - SF), 21-25% protein (high protein - HP) or > 25% protein (VHP). Protein intake increased up to day 7 (p < 0.0001). Patients on VHP received more protein than other groups (p < 0.0001). Multivariable regression analysis showed no evidence of harm. In fact, we observed increased mortality with SF and HP formulas at 30-days post-discharge when compared to patients on VHP even when the effects of other variables (including age, BMI, sex, primary diagnosis, diabetes, history of dialysis, ICU days kept NPO) were taken into consideration. CONCLUSIONS Increasing protein intake while reducing carbohydrate intake appears to be safe. Further research aimed at defining a causative effect of increasing protein delivery while reducing carbohydrate load on outcomes is warranted.
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Affiliation(s)
| | - Andrea Berger
- Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822, USA
| | - Raghad Hussein
- Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822, USA
| | - Maureen B Huhmann
- Nestle Health Science, 1007 US Highway 202/206, Building JR2, Bridgewater, NJ 08807, USA
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15
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Boelens YF, Strookappe B, Vasse E, Mensink M, van Zanten AR. The effect of an intervention of porcine protein versus maltodextrin supplement on CONvalescence of FUnCtional outcomes after IcU Stay (CONFUCIUS): Study protocol for a randomized controlled, single-center, double-blind trial. Clin Nutr ESPEN 2022; 52:86-93. [PMID: 36513490 DOI: 10.1016/j.clnesp.2022.10.008] [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: 06/24/2022] [Revised: 09/22/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients discharged from the Intensive Care Unit (ICU) frequently suffer from ICU-acquired weakness because of immobilization and massive inflammation-induced muscle mass loss. Consequently, rehospitalization, reduced quality of life (QoL), increased disabilities, and higher post-ICU mortality is observed. Exercise rehabilitation and optimal nutrition, particularly protein intake, are pivotal to regaining muscle mass and function. Studies have shown that protein requirements in the post-ICU phase are often unmet. Furthermore, protein supplementation in other patient groups has shown beneficial effects. However, a study on protein supplementation during the post-ICU period is lacking. This study aims to investigate the effect of a six-week intervention of daily porcine protein supplementation versus an isocaloric control (maltodextrin) on functional outcomes in the post-ICU period in patients with moderately severe ICU-acquired weakness. METHODS 72 post-ICU patients with moderately severe ICU-acquired weakness of Hospital Gelderse Vallei will be randomly assigned to either the intervention or the control group (36 per arm). The intervention group receives a porcine protein supplement twice a day. The control group receives a maltodextrin supplement twice a day. The intervention starts on the first day in the general ward and lasts 42 days (6 weeks). The primary outcome is the between-group difference in physical function at hospital discharge (t;=2), the end of the intervention (t;=3, day 42), and the 3-month follow-up (t;=4) expressed as a composite score consisting of handgrip strength, muscle strength leg, muscle strength arm and exercise capacity. Secondary outcomes encompass physical function, QoL, Activity of daily living (ADL), and plasma amino acids concentrations. Lastly, ICU readmission after ICU discharge, hospital readmission after hospital discharge, and overall survival status will be considered. Linear mixed models will be used to test the treatment effect for the primary and secondary outcome measures. DISCUSSION This trial will be the first to investigate porcine protein supplementation compared with carbohydrate supplementation in the post-ICU period aiming to improve functional outcomes of ICU survivors with moderately severe ICU-acquired weakness. TRIAL REGISTRATION The study has been registered at ClinicalTrials.gov. Number: NCT05405764.
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Affiliation(s)
- Yente Fn Boelens
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Stippenweg 4, 6708 WE Wageningen, the Netherlands.
| | - Bert Strookappe
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, the Netherlands; Department of Physiotherapy, Gelderse Vallei Hospital, Ede, the Netherlands.
| | - Emmelyne Vasse
- Department of Nutrition and Dietetic, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, the Netherlands.
| | - Marco Mensink
- Wageningen University & Research, Division of Human Nutrition and Health, Stippenweg 4, 6708 WE Wageningen, the Netherlands.
| | - Arthur Rh van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, the Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Stippenweg 4, 6708 WE Wageningen, the Netherlands.
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Impact of Energy and Protein Delivery to Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2022; 14:nu14224849. [PMID: 36432536 PMCID: PMC9698683 DOI: 10.3390/nu14224849] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
Optimal energy and protein delivery goals for critically ill patients remain unknown. The purpose of this systematic review and meta-analysis was to compare the impact of energy and protein delivery during the first 4 to 10 days of an ICU stay on physical impairments. We performed a systematic literature search of MEDLINE, CENTRAL, and ICHUSHI to identify randomized controlled trials (RCTs) that compared energy delivery at a cut-off of 20 kcal/kg/day or 70% of estimated energy expenditure or protein delivery at 1 g/kg/day achieved within 4 to 10 days after admission to the ICU. The primary outcome was activities of daily living (ADL). Secondary outcomes were physical functions, changes in muscle mass, quality of life, mortality, length of hospital stay, and adverse events. Fifteen RCTs on energy delivery and 14 on protein were included in the analysis. No significant differences were observed in any of the outcomes included for energy delivery. However, regarding protein delivery, there was a slight improvement in ADL (odds ratio 21.55, 95% confidence interval (CI) −1.30 to 44.40, p = 0.06) and significantly attenuated muscle loss (mean difference 0.47, 95% CI 0.24 to 0.71, p < 0.0001). Limited numbers of RCTs were available to analyze the effects of physical impairments. In contrast to energy delivery, protein delivery ≥1 g/kg/day achieved within 4 to 10 days after admission to the ICU significantly attenuated muscle loss and slightly improved ADL in critically ill patients. Further RCTs are needed to investigate their effects on physical impairments.
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17
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Dickerson RN, Andromalos L, Brown JC, Correia MITD, Pritts W, Ridley EJ, Robinson KN, Rosenthal MD, van Zanten ARH. Obesity and critical care nutrition: current practice gaps and directions for future research. Crit Care 2022; 26:283. [PMID: 36127715 PMCID: PMC9486775 DOI: 10.1186/s13054-022-04148-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
Abstract
Background This review has been developed following a panel discussion with an international group of experts in the care of patients with obesity in the critical care setting and focuses on current best practices in malnutrition screening and assessment, estimation of energy needs for patients with obesity, the risks and management of sarcopenic obesity, the value of tailored nutrition recommendations, and the emerging role of immunonutrition. Patients admitted to the intensive care unit (ICU) increasingly present with overweight and obesity that require individualized nutrition considerations due to underlying comorbidities, immunological factors such as inflammation, and changes in energy expenditure and other aspects of metabolism. While research continues to accumulate, important knowledge gaps persist in recognizing and managing the complex nutritional needs in ICU patients with obesity. Available malnutrition screening and assessment tools are limited in patients with obesity due to a lack of validation and heterogeneous factors impacting nutrition status in this population. Estimations of energy and protein demands are also complex in patients with obesity and may include estimations based upon ideal, actual, or adjusted body weight. Evidence is still sparse on the role of immunonutrition in patients with obesity, but the presence of inflammation that impacts immune function may suggest a role for these nutrients in hemodynamically stable ICU patients. Educational efforts are needed for all clinicians who care for complex cases of critically ill patients with obesity, with a focus on strategies for optimal nutrition and the consideration of issues such as weight stigma and bias impacting the delivery of care. Conclusions Current nutritional strategies for these patients should be undertaken with a focus on individualized care that considers the whole person, including the possibility of preexisting comorbidities, altered metabolism, and chronic stigma, which may impact the provision of nutritional care. Additional research should focus on the applicability of current guidelines and evidence for nutrition therapy in populations with obesity, especially in the setting of critical illness.
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18
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Gonzalez A, Abrigo J, Achiardi O, Simon F, Cabello-Verrugio C. Intensive care unit-acquired weakness: From molecular mechanisms to its impact in COVID-2019. Eur J Transl Myol 2022; 32. [PMID: 36036350 PMCID: PMC9580540 DOI: 10.4081/ejtm.2022.10511] [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: 04/12/2022] [Accepted: 08/08/2022] [Indexed: 01/08/2023] Open
Abstract
Intensive Care Unit-Acquired Weakness (ICU-AW) is a generalized and symmetric neuromuscular dysfunction associated with critical illness and its treatments. Its incidence is approximately 80% in intensive care unit patients, and it manifests as critical illness polyneuropathy, critical illness myopathy, and muscle atrophy. Intensive care unit patients can lose an elevated percentage of their muscle mass in the first days after admission, producing short- and long-term sequelae that affect patients’ quality of life, physical health, and mental health. In 2019, the world was faced with coronavirus disease 2019 (COVID-19), caused by the acute respiratory syndrome coronavirus 2. COVID-19 produces severe respiratory disorders, such as acute respiratory distress syndrome, which increases the risk of developing ICU-AW. COVID-19 patients treated in intensive care units have shown early diffuse and symmetrical muscle weakness, polyneuropathy, and myalgia, coinciding with the clinical presentation of ICU-AW. Besides, these patients require prolonged intensive care unit stays, invasive mechanical ventilation, and intensive care unit pharmacological therapy, which are risk factors for ICU-AW. Thus, the purposes of this review are to discuss the features of ICU-AW and its effects on skeletal muscle. Further, we will describe the mechanisms involved in the probable development of ICU-AW in severe COVID-19 patients.
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Zhu YB, Yao Y, Xu Y, Huang HB. Nitrogen balance and outcomes in critically ill patients: A systematic review and meta-analysis. Front Nutr 2022; 9:961207. [PMID: 36071933 PMCID: PMC9441883 DOI: 10.3389/fnut.2022.961207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveNitrogen balance (NB) is a commonly used nutrition indicator in clinical practice, while its relation to the interpretation of protein malnutrition and outcomes in critically ill patients remains unclear. This study aimed to evaluate the impact of NB on prognosis in such a patient population.MethodsWe searched for relevant studies in PubMed, EMBASE, and the Cochrane Database up to May 10, 2022. Meta-analyses were performed to evaluate the relationship between NB (initial, final, or absolute change of NB levels) and prognosis and important clinical outcomes in critically ill patients. Pooled odds ratios (ORs) and mean differences (MDs) together with their 95% confidence intervals (CIs) were calculated. We also conducted subgroup analyses to explore the sources of heterogeneity.ResultsEight studies with 1,409 patients were eligible. These studies were moderate to high quality. When pooled, the initial NB was comparable between the survival and non-survival groups (five studies, MD 1.20, 95% CI, −0.70 to 3.11, I2 = 77%; P = 0.22), while a significantly higher final NB in the survival group than that in the death group (two studies, MD 3.69, 95% CI, 1.92–5.46, I2 = 55%; P < 0.0001). Two studies provided the absolute change of NB over time and suggested survival patients had more increased NB (MD 4.16 g/day, 95% CI, 3.70–4.61, I2 = 0%; P < 0.00001). Similarly, for studies utilizing multivariate logistic regression, we found an improved NB (four studies, OR 0.85, 95% CI, 0.73–0.99, I2 = 61%; P = 0.04) but not an initial NB (two studies, OR 0.92, 95% CI 0.78–1.08, I2 = 55%; P = 0.31) was significantly associated the risk of all-cause mortality. These results were further confirmed in subgroup analyses. In addition, patients with improved NB had more protein and calorie intake and a similar length of stay in hospital than those without.ConclusionsOur results suggested that an improved NB but not the initial NB level was associated with all-cause mortality in critically ill patients. This highlights the requirement for dynamic monitoring of NB during nutrition treatment. Further randomized clinical trials examining the impact of NB-guided protein intake on clinical outcomes in critically ill patients are warranted.Systematic review registrationINPLASY202250134, https://doi.org/10.37766/inplasy2022.5.0134.
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Affiliation(s)
- Yi-Bing Zhu
- Department of Emergency, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Yao
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- *Correspondence: Hui-Bin Huang
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20
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Murthy TA, Bellomo R, Chapman MJ, Deane AM, Ferrie S, Finnis ME, Hurford S, O’Connor SN, Peake SL, Summers MJ, Williams PJ, Young PJ, Chapple LAS. Protein delivery in mechanically ventilated adults in Australia and New Zealand: current practice. CRIT CARE RESUSC 2021; 23:386-393. [PMID: 38046685 PMCID: PMC10692581 DOI: 10.51893/2021.4.oa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To quantify current protein prescription and delivery in critically ill adults in Australia and New Zealand and compare it with international guidelines. Design: Prospective, multicentre, observational study. Setting: Five intensive care units (ICUs) across Australia and New Zealand. Participants: Mechanically ventilated adults who were anticipated to receive enteral nutrition for ≥ 24 hours. Main outcome measures: Baseline demographic and nutrition data in ICU, including assessment of requirements, prescription and delivery of enteral nutrition, parenteral nutrition and protein supplementation, were collected. The primary outcome was enteral nutrition protein delivery (g/kg ideal body weight [IBW] per day). Data are reported as mean ± standard deviation or n (%). Results: 120 patients were studied (sex, 60% male; mean age, 59 ± 16 years; mean admission APACHE II score, 20 ± 8). Enteral nutrition was delivered on 88%, parenteral nutrition on 6.8%, and protein supplements on 0.3% of 1156 study days. For the 73% (88/120) of patients who had a nutritional assessment, the mean estimated protein requirements were 99 ± 22 g/day (1.46 ± 0.55 g/kg IBW per day). The mean daily protein delivery was 54 ± 23 g (0.85 ± 0.35 g/kg IBW per day) from enteral nutrition and 56 ± 23 g (0.88 ± 0.35 g/kg IBW per day) from all sources (enteral nutrition, parenteral nutrition, protein supplements). Protein delivery was ≥ 1.2 g/kg IBW per day on 29% of the total study days per patient. Conclusions: Protein delivery as a part of current usual care to critically ill adults in Australia and New Zealand remains below that recommended in international guidelines.
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Affiliation(s)
- Tejaswini Arunachala Murthy
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Stephanie N. O’Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Paul J. Young
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
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21
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Compher C, Bingham AL, McCall M, Patel J, Rice TW, Braunschweig C, McKeever L. Guidelines for the provision of nutrition support therapy in the adult critically Ill patient: American society for parenteral and enteral nutrition. JPEN J Parenter Enteral Nutr 2021; 46:12-41. [PMID: 34784064 DOI: 10.1002/jpen.2267] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND New randomized controlled trials have been conducted since publication of the 2016 ASPEN/SCCM critical care nutrition guideline. This guideline updates recommendations for foundational questions central to critical care nutrition support. METHODS The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose (2) higher vs lower protein dose (3) exclusive isocaloric PN vs EN (4) supplemental PN (SPN) plus EN vs EN alone (5a) mixed oil lipid injectable emulsions (ILE) vs soybean oil, and (5b) Fish oil (FO) containing ILE vs non-FO ILE. To assess safety, weight based energy intake was plotted against hospital mortality when study heterogeneity precluded meaningful Forest plot inferences. RESULTS Between 1/1/2001 and 07/15/2020, 2,320 citations were identified and data were abstracted from 39 trials, including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Due to lack in certainty regarding harm, the energy prescription recommendation was decreased to 12-25kcal/kg/day. CONCLUSION No differences in clinical outcomes were identified among numerous nutritional interventions, including higher energy or protein intake, isocaloric PN or EN, supplemental PN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Charlene Compher
- Biobehavioral Health Sciences Department, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angela L Bingham
- Department of Pharmacy, Cooper University Hospital, Camden, New Jersey, USA.,Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania, USA
| | - Michele McCall
- St. Michael's Hospital, Medical/Surgical Intensive Care Unit, Toronto, ON, Canada
| | - Jayshil Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carol Braunschweig
- Division of Epidemiology and Biostatistics, Department of Kinesiology and Nutrition, University of Illinois, Chicago, Illinois, USA
| | - Liam McKeever
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Dreydemy G, Coussy A, Lannou A, Petit L, Biais M, Carrié C. Augmented Renal Clearance, Muscle Catabolism and Urinary Nitrogen Loss: Implications for Nutritional Support in Critically Ill Trauma Patients. Nutrients 2021; 13:nu13103554. [PMID: 34684555 PMCID: PMC8540369 DOI: 10.3390/nu13103554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/03/2021] [Accepted: 10/09/2021] [Indexed: 02/07/2023] Open
Abstract
The main objective of this pilot study was to determine the association between augmented renal clearance (ARC), urinary nitrogen loss and muscle wasting in critically ill trauma patients. We conducted a retrospective analysis of a local database in 162 critically ill trauma patients without chronic renal dysfunction. Nutritional-related parameters and 24 h urinary biochemical analyses were prospectively collected and averaged over the first ten days after admission. Augmented renal clearance was defined by a mean creatinine clearance (CLCR) > 130 mL/min/1.73 m2. The main outcome was the cumulated nitrogen balance at day 10. The secondary outcome was the variation of muscle psoas cross-sectional area (ΔCSA) calculated in the subgroup of patients who underwent at least two abdominal CT scans during the ICU length of stay. Overall, there was a significant correlation between mean CLCR and mean urinary nitrogen loss (normalized coefficient: 0.47 ± 0.07, p < 0.0001). ARC was associated with a significantly higher urinary nitrogen loss (17 ± 5 vs. 14 ± 4 g/day, p < 0.0001) and a lower nitrogen balance (−6 ± 5 vs. −4 ± 5 g/day, p = 0.0002), without difference regarding the mean protein intake (0.7 ± 0.2 vs. 0.7 ± 0.3 g/kg/day, p = 0.260). In the subgroup of patients who underwent a second abdominal CT scan (N = 47), both ΔCSA and %ΔCSA were higher in ARC patients (−33 [−41; −25] vs. −15 [−29; −5] mm2/day, p = 0.010 and −3 [−3; −2] vs. −1 [−3; −1] %/day, p = 0.008). Critically ill trauma patients with ARC are thus characterized by a lower nitrogen balance and increased muscle loss over the 10 first days after ICU admission. The interest of an increased protein intake (>1.5 g/kg/day) in such patients remains a matter of controversy and must be confirmed by further randomized trials.
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Affiliation(s)
- Guilhem Dreydemy
- Anesthesiology and Critical Care Department, CHU Pellegrin, 33000 Bordeaux, France; (A.L.); (L.P.); (M.B.); (C.C.)
- Correspondence:
| | - Alexis Coussy
- Radiology Department, CHU Pellegrin, 33000 Bordeaux, France;
| | - Alexandre Lannou
- Anesthesiology and Critical Care Department, CHU Pellegrin, 33000 Bordeaux, France; (A.L.); (L.P.); (M.B.); (C.C.)
| | - Laurent Petit
- Anesthesiology and Critical Care Department, CHU Pellegrin, 33000 Bordeaux, France; (A.L.); (L.P.); (M.B.); (C.C.)
| | - Matthieu Biais
- Anesthesiology and Critical Care Department, CHU Pellegrin, 33000 Bordeaux, France; (A.L.); (L.P.); (M.B.); (C.C.)
- Health Department, University Bordeaux Segalen, 33000 Bordeaux, France
| | - Cédric Carrié
- Anesthesiology and Critical Care Department, CHU Pellegrin, 33000 Bordeaux, France; (A.L.); (L.P.); (M.B.); (C.C.)
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23
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Lyons GCE, Summers MJ, Schultz TJ, Lambell K, Ridley EJ, Fetterplace K, Yandell R, Chapple LS. Protein prescription and delivery practices in critically ill adults: A survey of Australian and New Zealand intensive care dietitians. Aust Crit Care 2021; 35:543-549. [PMID: 34556388 DOI: 10.1016/j.aucc.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance. OBJECTIVES The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions. METHODS A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions. RESULTS Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present. CONCLUSIONS Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.
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Affiliation(s)
- G C E Lyons
- Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - M J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - T J Schultz
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; Adelaide Nursing School, The University of Adelaide, Adelaide, South Australia, Australia
| | - K Lambell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Nutrition Department, Alfred Health, Melbourne, Australia
| | - E J Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Nutrition Department, Alfred Health, Melbourne, Australia
| | - K Fetterplace
- Allied Health Department (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Melbourne, Australia
| | - R Yandell
- Department of Clinical Dietetics, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia
| | - L S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia.
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24
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Rusli C, Bukhari A, A Taslim N, As'ad S, Rasyid H. Nutrition Therapy in Critically Ill Overweight Elderly Patient with Heart Failure, Myocardial Infarction, Pneumonia, and Chronic Kidney Disease. J Nutr Sci Vitaminol (Tokyo) 2021; 66:S25-S31. [PMID: 33612605 DOI: 10.3177/jnsv.66.s25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Overweight or obesity will increase the risk of morbidity and mortality from cardiovascular disease. In older people, the risk is higher, but also paradoxically associated with lower mortality rates. Overweight patients vary in body composition and when it coupled with limited reliable sources to make caloric requirements estimation will make nutrition therapy extremely challenging. This case study reveals the nutrition therapy support in critically ill overweight elderly patient with heart failure, myocardial infarction, pneumonia, and chronic kidney disease. An 80-year old moderate malnourished male patient (body mass index 24.6 kg/m2) with acute lung edema, cardiogenic shock, myocardial infarction, pneumonia, and chronic kidney disease was admitted in the cardiovascular intensive-care unit. The patient was treated with diuretics, vasopressor support, and antibiotics. Oral intake was reduced due to shortness of breath and loss of appetite. The physical examination revealed basal lung rales, wheezing, muscle wasting, edema. Blood tests showed hyperkalemia, leucocytosis, depletion of the immune system, hyperuricemia, hypoalbuminemia, and dyslipidemia. The patient was on stage 5 renal failure (GFR 6.2 mL/min) but refused hemodialysis treatment. Nutritional therapy was given gradually with calorie target 1900 kcal and protein 0.6-1.2 g/ideal body weight/d using normal foods, oral nutrition supplement, and amino acids parenteral nutrition. After 13 d of nutritional treatment, the patient was discharged from the hospital with no shortness of breath, adequate nutrition intake, increased renal function (GFR 22.4 mL/min), and improvement of the blood test results (immune status, uric acid, albumin, and lipid profile). Critically ill overweight elderly patients are hypercatabolic and have increased nutrient demands. Nutritional support in these patients is required to provide necessary nutrient substrates and to alter the course and outcome of the disease.
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Affiliation(s)
- Christina Rusli
- Clinical Nutrition Specialist Program, Faculty of Medicine, Hasanuddin University
| | - Agussalim Bukhari
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Nurpudji A Taslim
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Suryani As'ad
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University
| | - Haerani Rasyid
- Department of Nutritional Science, Faculty of Medicine, Hasanuddin University.,Department of Internal Medicine, Faculty of Medicine, Hasanuddin University
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25
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). J Intensive Care 2021; 9:53. [PMID: 34433491 PMCID: PMC8384927 DOI: 10.1186/s40560-021-00555-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Affiliation(s)
- Moritoki Egi
- Department of Surgery Related, Division of Anesthesiology, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ku, Kobe, Hyogo, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Medical School, Yamadaoka 2-15, Suita, Osaka, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuaki Atagi
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Joji Kotani
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Hosokawa
- Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mai Inada
- Member of Japanese Association for Acute Medicine, Tokyo, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Support and Practice, Hiroshima University Hospital, Hiroshima, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Japan
| | | | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine/Infectious Disease, Hitachi General Hospital, Hitachi, Japan
| | - Kei Hayashida
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Shinya Miura
- The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kohkichi Andoh
- Division of Anesthesiology, Division of Intensive Care, Division of Emergency and Critical Care, Sendai City Hospital, Sendai, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yusuke Ito
- Department of Infectious Disease, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akemi Utsunomiya
- Human Health Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Akira Ouchi
- College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Masayuki Ozaki
- Department of Emergency and Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Satoshi Ono
- Gastroenterological Center, Shinkuki General Hospital, Kuki, Japan
| | | | | | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | | | - Akira Shimoyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Tokai University School of Medicine, Isehara, Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, Nagasaki, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei Takahashi
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Goro Tajima
- Nagasaki University Hospital Acute and Critical Care Center, Nagasaki, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Tani
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaharu Nagae
- Department of Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | | | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shin Nunomiya
- Department of Anesthesiology and Intensive Care Medicine, Division of Intensive Care, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoki Hara
- Department of Pharmacy, Yokohama Rosai Hospital, Yokohama, Japan
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Hirotaka Furusono
- Department of Rehabilitation, University of Tsukuba Hospital/Exult Co., Ltd., Tsukuba, Japan
| | - Yujiro Matsuishi
- Doctoral program in Clinical Sciences. Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Minematsu
- Department of Clinical Engineering, Osaka University Hospital, Suita, Japan
| | - Ryoichi Miyashita
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuji Miyatake
- Department of Clinical Engineering, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Megumi Moriyasu
- Division of Respiratory Care and Rapid Response System, Intensive Care Center, Kitasato University Hospital, Sagamihara, Japan
| | - Toru Yamada
- Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuhei Yoshida
- Nursing Department, Osaka General Medical Center, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Asai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masami Ishikawa
- Department of Anesthesiology, Emergency and Critical Care Medicine, Kure Kyosai Hospital, Kure, Japan
| | - Go Ishimaru
- Department of General Internal Medicine, Soka Municipal Hospital, Soka, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryuta Itakura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hisashi Imahase
- Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Kenji Uehara
- Department of Anesthesiology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Noritaka Ushio
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yuko Egawa
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Takanori Ohno
- Department of Emergency and Critical Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Okamoto
- Department of ER, Hashimoto Municipal Hospital, Hashimoto, Japan
| | - Hiroshi Okuda
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takayuki Ogura
- Tochigi prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Yu Onodera
- Department of Anesthesiology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yuhta Oyama
- Department of Internal Medicine, Dialysis Center, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Motoshi Kainuma
- Anesthesiology, Emergency Medicine, and Intensive Care Division, Inazawa Municipal Hospital, Inazawa, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya-City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Kanaya
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Keita Kanehata
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, Onga Hospital, Fukuoka, Japan
| | - Kazuya Kikutani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Kimura
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyuki Koami
- Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, USA
| | - Daisuke Kobashi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Iwao Saiki
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Masahito Sakai
- Department of General Medicine Shintakeo Hospital, Takeo, Japan
| | - Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tetsuya Sato
- Tohoku University Hospital Emergency Center, Sendai, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Manabu Shimoto
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Shimoyama
- Department of Pediatric Cardiology and Intensive Care, Gunma Children's Medical Center, Shibukawa, Japan
| | - Tomohisa Shoko
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Yokohama City University, Yokohama, Japan
| | - Atsunori Sugita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Intensive Care, Okayama University Hospital, Okayama, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Takahashi
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Yoko Takahashi
- Department of General Internal Medicine, Koga General Hospital, Koga, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yuuki Tanaka
- Fukuoka Prefectural Psychiatric Center, Dazaifu Hospital, Dazaifu, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Taichiro Tsunoyama
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenichi Tetsuhara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kentaro Tokunaga
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshihiro Tomioka
- Department of Anesthesiology and Intensive Care Unit, Todachuo General Hospital, Toda, Japan
| | - Kentaro Tomita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukitoshi Toyoda
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshimi Nakamura
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuki Nakamori
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoya Nishimura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kei Nishiyama
- Division of Emergency and Critical Care Medicine Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Katsuhiko Hashimoto
- Research Associate of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshiaki Hamasaki
- Department of Emergency Medicine, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuya Hayashi
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Atsuki Hayamizu
- Department of Emergency Medicine, Saitama Saiseikai Kurihashi Hospital, Kuki, Japan
| | - Go Haraguchi
- Division of Intensive Care Unit, Sakakibara Heart Institute, Tokyo, Japan
| | - Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Ryo Fujii
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Foundation Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Masahito Horiguchi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Jun Maki
- Department of Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Naohisa Masunaga
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan
| | - Takuya Mayumi
- Department of Internal Medicine, Kanazawa Municipal Hospital, Kanazawa, Japan
| | - Keisuke Minami
- Ishikawa Prefectual Central Hospital Emergency and Critical Care Center, Kanazawa, Japan
| | - Yuya Miyazaki
- Department of Emergency and General Internal Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, Tokyo, Japan
| | - Teppei Murata
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takao Yano
- Department of Critical Care and Emergency Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tomonori Yamamoto
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shodai Yoshihiro
- Pharmaceutical Department, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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Hill A, Elke G, Weimann A. Nutrition in the Intensive Care Unit-A Narrative Review. Nutrients 2021; 13:nu13082851. [PMID: 34445010 PMCID: PMC8400249 DOI: 10.3390/nu13082851] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, D-52074 Aachen, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Surgical Intensive Care Unit, Klinikum St. Georg, D-04129 Leipzig, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
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Gala K, Desai V, Liu N, Omer EM, McClave SA. How to Increase Muscle Mass in Critically Ill Patients: Lessons Learned from Athletes and Bodybuilders. Curr Nutr Rep 2021; 9:369-380. [PMID: 33098051 DOI: 10.1007/s13668-020-00334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Decades of research on nutrition and exercise on athletes and bodybuilders has yielded various strategies to promote anabolism and improve muscle health and growth. We reviewed these interventions in the context of muscle loss in critically ill patients. RECENT FINDINGS For critically ill patients, ensuring optimum protein intake is important, potentially using a whey-containing source and supplemented with vitamin D and leucine. Agents like hydroxyl β-methylbutyrate and creatine can be used to promote muscle synthesis. Polyunsaturated fatty acids stimulate muscle production as well as have anti-inflammatory properties that may be useful in critical illness. Adjuncts like oxandralone promote anabolism. Resistance training has shown mixed results in the ICU setting but needs to be explored further with specific outcomes. Critically ill patients suffer from severe proteolysis during hospitalization as well as persistent inflammation, immunosuppression, and catabolism syndrome after discharge. High protein supplementation, ergogenic aids, anti-inflammatories, and anabolic adjuncts have shown potential in alleviating muscle loss and should be used in intensive care units to optimize patient recovery.
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Affiliation(s)
- Khushboo Gala
- Department of Internal Medicine, University of Louisville, 550 S Jackson Street, 3rd Floor, Ambulatory Care Building, Louisville, KY, 40202, USA.
| | - Viral Desai
- Department of Internal Medicine, University of Louisville, 550 S Jackson Street, 3rd Floor, Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Nanlong Liu
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Endashaw M Omer
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Stephen A McClave
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
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Lee ZY, Yap CSL, Hasan MS, Engkasan JP, Barakatun-Nisak MY, Day AG, Patel JJ, Heyland DK. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:260. [PMID: 34301303 PMCID: PMC8300989 DOI: 10.1186/s13054-021-03693-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/15/2021] [Indexed: 12/17/2022]
Abstract
Background The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. Methods We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Results Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75–1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD −3.44% per week, 95% CI −4.99 to −1.90; p < 0.0001). Conclusion In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03693-4.
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Affiliation(s)
- Zheng-Yii Lee
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Sing Ling Yap
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - M Shahnaz Hasan
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Julia Patrick Engkasan
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd Yusof Barakatun-Nisak
- Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Institute for Social Science Studies, Universiti Putra Malaysia, Serdang, Malaysia
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | | | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
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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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Battaglini D, Robba C, Fedele A, Trancǎ S, Sukkar SG, Di Pilato V, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Ball L, Brunetti I, Torres Martí A, Rocco PRM, Pelosi P. The Role of Dysbiosis in Critically Ill Patients With COVID-19 and Acute Respiratory Distress Syndrome. Front Med (Lausanne) 2021; 8:671714. [PMID: 34150807 PMCID: PMC8211890 DOI: 10.3389/fmed.2021.671714] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
In late December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) quickly spread worldwide, and the syndrome it causes, coronavirus disease 2019 (COVID-19), has reached pandemic proportions. Around 30% of patients with COVID-19 experience severe respiratory distress and are admitted to the intensive care unit for comprehensive critical care. Patients with COVID-19 often present an enhanced immune response with a hyperinflammatory state characterized by a "cytokine storm," which may reflect changes in the microbiota composition. Moreover, the evolution to acute respiratory distress syndrome (ARDS) may increase the severity of COVID-19 and related dysbiosis. During critical illness, the multitude of therapies administered, including antibiotics, sedatives, analgesics, body position, invasive mechanical ventilation, and nutritional support, may enhance the inflammatory response and alter the balance of patients' microbiota. This status of dysbiosis may lead to hyper vulnerability in patients and an inappropriate response to critical circumstances. In this context, the aim of our narrative review is to provide an overview of possible interaction between patients' microbiota dysbiosis and clinical status of severe COVID-19 with ARDS, taking into consideration the characteristic hyperinflammatory state of this condition, respiratory distress, and provide an overview on possible nutritional strategies for critically ill patients with COVID-19-ARDS.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Università degli Studi di Genova, Genova, Italy
| | - Andrea Fedele
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Sebastian Trancǎ
- Department of Anesthesia and Intensive Care II, Clinical Emergency County Hospital of Cluj, Iuliu Hatieganu, University of Medicine and Pharmacy, Cluj-Napoca, Romania
- Anaesthesia and Intensive Care 1, Clinical Emergency County Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - Samir Giuseppe Sukkar
- Dietetics and Clinical Nutrition Unit, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Università degli Studi di Genova, Genova, Italy
| | - Matteo Bassetti
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Dipartimento di Scienze della Salute (DISSAL), Università degli Studi di Genova, Genova, Italy
| | - Daniele Roberto Giacobbe
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Dipartimento di Scienze della Salute (DISSAL), Università degli Studi di Genova, Genova, Italy
| | - Antonio Vena
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Nicolò Patroniti
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Università degli Studi di Genova, Genova, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Università degli Studi di Genova, Genova, Italy
| | - Iole Brunetti
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Antoni Torres Martí
- Department of Medicine, University of Barcelona, Barcelona, Spain
- Division of Animal Experimentation, Department of Pulmonology, Hospital Clinic, Barcelona, Spain
- Centro de Investigacion en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Institut d'investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- COVID-19-Network, Ministry of Science, Technology, Innovation and Communication, Brasilia, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l'Oncologia e le Neuroscienze, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Università degli Studi di Genova, Genova, Italy
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Abstract
PURPOSE OF REVIEW Progress has been made in our understanding of gut dysfunction in critical illness. This review will outline new findings and give perspectives based on previous knowledge and concurrent advances in nutrition. RECENT FINDINGS The relationship between gut dysfunction and poor outcomes in critical illness has received considerable interest. It remains uncertain whether gut dysfunction is merely a marker of illness severity or if it is directly responsible for prolonged critical illness and increased mortality. This relationship is difficult to ascertain given there is no agreed method for identification and quantification; biomarkers such as intestinal fatty acid binding protein and citrulline show promise but require further study. Recent studies have investigated strategies to deliver enteral nutrition targets with impacts on gut function, including high calorie or protein formulae, intermittent regimes and novel prokinetics. SUMMARY Gut dysfunction is associated with poor outcomes, but it remains uncertain whether strategies to improve gut function will influence survival and recovery.
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van Gassel RJJ, van de Poll MCG, Schaap FG, Plummer M, Deane A, Olde Damink SWM. Postprandial rise of essential amino acids is impaired during critical illness and unrelated to small-intestinal function. JPEN J Parenter Enteral Nutr 2021; 46:114-122. [PMID: 33666262 PMCID: PMC9293041 DOI: 10.1002/jpen.2103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Postprandial rise of plasma essential amino acids (EAAs) determines the anabolic effect of dietary protein. Disturbed gastrointestinal function could impair the anabolic response in critically ill patients. Aim was to investigate the postprandial EAA response in critically ill patients and its relation to small‐intestinal function. Methods Twenty‐one mechanically ventilated patients and 9 healthy controls received a bolus containing 100 ml of a formula feed (Ensure) and 2 g of 3‐O‐Methyl‐d‐glucose (3‐OMG) via postpyloric feeding tube. Fasting and postprandial plasma concentrations of EAAs, 3‐OMG, total bile salts, and the gut‐released hormone fibroblast growth factor 19 (FGF19) were measured over a 4‐hour period. Changes over time and between groups were assessed with linear mixed‐effects analysis. Early (0–60 minutes) and total postprandial responses are summarized as the incremental area under the curve (iAUC). Results At baseline, fasting EAA levels were similar in both groups: 1181 (1055–1276) vs 1150 (1065–1334) μmol·L−1, P = .87. The early postprandial rise in EAA was not apparent in critically ill patients compared with healthy controls (iAUC60, −4858 [−6859 to 2886] vs 5406 [3099–16,853] µmol·L−1·60 minutes; P = .039). Impaired EAA response did not correlate with impaired 3‐OMG response (Spearman ρ 0.32, P = .09). There was a limited increase in total bile salts but no relevant FGF19 response in either group. Conclusion Postprandial rise of EAA is blunted in critically ill patients and unrelated to glucose absorption measured with 3‐OMG. Future studies should aim to delineate governing mechanisms of macronutrient malabsorption.
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Affiliation(s)
- Rob J J van Gassel
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - Marcel C G van de Poll
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - Frank G Schaap
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Mark Plummer
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam Deane
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Steven W M Olde Damink
- Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
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Medical high-protein nutrition therapy and loss of muscle mass in adult ICU patients: A randomized controlled trial. Clin Nutr 2021; 40:1562-1570. [PMID: 33743292 DOI: 10.1016/j.clnu.2021.02.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The degradation of muscle mass and loss of functional proteins due to catabolism are associated with adverse outcomes in critically ill patients. While an adequate supply of protein within a medical nutrition concept is suggested to minimize proteolysis, the specificities on appropriate dosage and timing are still under debate. The current study aimed to evaluate the effect of two different quantities of protein as part of a standardized energetically controlled nutrition therapy for the preservation of muscle mass in the later phase of critical illness. METHODS A randomized controlled trial was conducted in 42 critically ill patients (age 65 ± 15; 12 females; SAPS 45 ± 11; TISS 20 ± 7; SOFA-score 7 ± 3). The subjects were randomly assigned to either the intervention (1.8 g protein/kg body weight [BW]/d) or standard (1.2 g protein/kg BW/d) group. Nutrient supply via enteral and/or parenteral nutrition was calculated based on the individual energy expenditure measured by indirect calorimetry and target protein content. Quadriceps muscle layer thickness (QMLT) was observed through sonography at inclusion, and during the follow-up period, two and four weeks after inclusion. The measurement points were fixed on two sides at the midpoint and two-thirds between the anterior superior iliac spine and top of the patella. The data were analyzed descriptively wherein chi-squared tests or unpaired two-samle t-tests checked group differences. Daily changes in muscle mass were estimated using a linear mixed model. All data are shown as the mean ± standard deviation (SD). RESULTS Actual protein intake reached 1.5 ± 0.5 g and 1.0 ± 0.5 g/kg BW/d in the intervention and standard group, respectively. Mean values of all measurements of QMLT at inclusion (day 13 ± 2 after ICU admission) were 13.5 ± 7.4 mm and 13.4 ± 7.1 mm in the intervention and standard group, respectively (P = 0.967). In both the groups, QMLT decreased over time (P < 0.001), while the estimated mean values of daily QMLT changes were -0.15 ± 0.08 mm (intervention) and -0.28 ± 0.08 mm (standard) without significant between-group differences (intervention effect, P = 0.368; time x intervention effect, P = 0.242). Illness scores and clinical outcomes showed no group differences. CONCLUSION In this single-center trial the increased amounts of protein (1.5 g vs. 1.0 g/kg BW/d) provided through medical nutrition therapy in the late phase of critical illness did not achieve a statistically significant impact on the loss of muscle mass in long-term immobilized ICU patients. Larger multi-center trials are needed to evaluate whether observed numerical differences in muscle mass could be a true finding, and will translate into improved clinical outcomes. TRIAL REGISTRATION German Clinical Trials Register (http://www.drks.de/), DRKS-ID: DRKS00013594.
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Carteron L, Samain E, Winiszewski H, Blasco G, Balon AS, Gilli C, Piton G, Capellier G, Pili-Floury S, Besch G. Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:31. [PMID: 33472680 PMCID: PMC7818740 DOI: 10.1186/s13054-020-03456-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022]
Abstract
Background The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. Methods Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. Results Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44–65] versus 55[40–65] years) and GCS (6[3–7] versus 5[3–7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78–1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group. Conclusion Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. Trial registration EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).
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Affiliation(s)
- Laurent Carteron
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France. .,EA3920, University of Franche Comté, Besancon, France.
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France.,EA3920, University of Franche Comté, Besancon, France
| | - Hadrien Winiszewski
- EA3920, University of Franche Comté, Besancon, France.,Medical Intensive Care Unit, University Hospital of Besancon, Besancon, France
| | - Gilles Blasco
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France
| | - Anne-Sophie Balon
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France
| | - Camille Gilli
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France
| | - Gael Piton
- EA3920, University of Franche Comté, Besancon, France.,Medical Intensive Care Unit, University Hospital of Besancon, Besancon, France
| | - Gilles Capellier
- EA3920, University of Franche Comté, Besancon, France.,Medical Intensive Care Unit, University Hospital of Besancon, Besancon, France
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France.,EA3920, University of Franche Comté, Besancon, France
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France.,EA3920, University of Franche Comté, Besancon, France
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss recent findings related to providing adequate and well tolerated nutrition to the critically ill surgical patient. RECENT FINDINGS The majority of nutritional studies in the critically ill have been performed on well nourished patients, but validated scoring systems can now identify high nutrition risk patients. Although it remains well accepted that early enteral nutrition with protein supplementation is key, mechanistic data suggest that hypocaloric feeding in septic patients may be beneficial. For critically ill patients unable to tolerate enteral nutrition, randomized pilot data demonstrate improved functional outcomes with early supplemental parenteral nutrition. Current guidelines also recommend early total parenteral nutrition in high nutrition risk patients with contraindications to enteral nutrition. When critically ill patients require low or moderate-dose vasopressors, enteral feeding appears well tolerated based on a large database study, while randomized prospective data showed worse outcomes in patients receiving high-dose vasopressors. SUMMARY Current evidence suggests early enteral nutrition with protein supplementation in critically ill surgical patients with consideration of early parenteral nutrition in high nutrition risk patients unable to achieve nutrition goals enterally. Despite established guidelines for nutritional therapy, the paucity of data to support these recommendations illustrates the critical need for additional studies.
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada T, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano K, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). Acute Med Surg 2021; 8:e659. [PMID: 34484801 PMCID: PMC8390911 DOI: 10.1002/ams2.659] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Chapple LAS, Summers MJ, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Finnis ME, Hurford S, Lange K, Little L, O'Connor SN, Peake SL, Ridley EJ, Young PJ, Williams PJ, Deane AM. Use of a High-Protein Enteral Nutrition Formula to Increase Protein Delivery to Critically Ill Patients: A Randomized, Blinded, Parallel-Group, Feasibility Trial. JPEN J Parenter Enteral Nutr 2020; 45:699-709. [PMID: 33296079 DOI: 10.1002/jpen.2059] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. METHODS We conducted a prospective, randomized, blinded, parallel-group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). RESULTS The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high-protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38-0.69] g/kg/d protein), with no difference in energy delivery (difference, -26 [95% CI, -190 to 137] kcal/kg/d). There were no between-group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90-day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, -1.3% [95% CI, -17.7% to 15.0%]). CONCLUSION Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline-recommended levels with doses similar to usual care during critical illness.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Matthew J Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia.,The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, Frankston Hospital, Frankston, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Patricia J Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Adam M Deane
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia
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- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Nakamura K, Nakano H, Naraba H, Mochizuki M, Takahashi Y, Sonoo T, Hashimoto H, Morimura N. High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial. Clin Nutr 2020; 40:796-803. [PMID: 32800385 DOI: 10.1016/j.clnu.2020.07.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Appropriate protein delivery amounts during the acute phase of critical care are unknown. Along with nutrition, early mobilization and the combination are important. We conducted a randomized controlled trial during critical care to assess high-protein and medium-protein delivery under equal total energy delivery with and without active early rehabilitation. METHODS ICU patients of August 2018-September 2019 were allocated to a high-protein group (target energy 20 kcal/kg/day, protein 1.8 g/kg/day) or a medium-protein group (target energy 20 kcal/kg/day, protein 0.9 g/kg/day) with the same nutrition protocol by day 10. By dividing the study period, standard rehabilitation was administered during the initial period. Rehabilitation with belt-type electrical muscle stimulation was given from day 2 in the latter as a historical comparison. Femoral muscle volume was evaluated on day 1 and day 10 using computed tomography. RESULTS This study analyzed 117 eligible patients with similar characteristics assigned to a high-protein or medium-protein group. Total energy delivery was around 20 kcal/kg/day in both groups, but protein delivery was 1.5 g/kg/day and 0.8 g/kg/day. As a primary outcome, femoral muscle volume loss was 12.9 ± 8.5% in the high-protein group and 16.9 ± 7.0% in the medium-protein group, with significant difference (p = 0.0059). Persistent inflammation, immunosuppression, and catabolism syndrome were significantly less frequent in the high-protein group. Muscle volume loss was significantly less in the high-protein group only during the electrical muscle stimulation period. CONCLUSIONS For critical care, high protein delivery provided better muscle volume maintenance, but only with active early rehabilitation. REGISTRATION University Hospital Medical Information Network, UMIN000033783 Registered on 16 Aug 2018. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038538.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan; TXP Medical Co. Ltd., 3-13 Nihonbashiyokoyamacho, Chuo-ku, Tokyo, 103-0003, Japan.
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan; TXP Medical Co. Ltd., 3-13 Nihonbashiyokoyamacho, Chuo-ku, Tokyo, 103-0003, Japan.
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Naoto Morimura
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan.
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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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Translating the European Society for Clinical Nutrition and Metabolism 2019 guidelines into practice. Curr Opin Crit Care 2020; 25:314-321. [PMID: 31107309 DOI: 10.1097/mcc.0000000000000619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To present a pragmatic approach to facilitate clinician's implementing the recent European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on clinical nutrition in the intensive care unit. RECENT FINDINGS The ESPEN guidelines include 54 recommendations with a rationale for each recommendation. All data published since 1 January 2000 was reviewed and 31 meta-analyses were performed to inform these guidelines. An important aspect of the most recent ESPEN guidelines is an attempt to separate periods of critical illness into discrete - early acute, late acute and recovery - phases, with each exhibiting different metabolic profiles and requiring different strategies for nutritional and metabolic support. SUMMARY A pragmatic approach to incorporate the recent ESPEN guidelines into everyday clinical practice is provided.
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Abstract
PURPOSE OF REVIEW To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years. RECENT FINDINGS Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders. The use of ultrasonography to identify upper gastrointestinal dysmotility appears promising. Both nonpharmacological and pharmacological approaches to treat gastrointestinal dysmotility have recently been evaluated. These approaches include modification of macronutrient content and administration of promotility drugs, stool softeners or laxatives. Although these approaches may reduce features of gastrointestinal dysmotility, none have translated to patient-centred benefit. SUMMARY 'Off-label' metoclopramide and/or erythromycin administration are effective for upper gastrointestinal dysmotility but have adverse effects. Trials of alternative or novel promotility drugs have not demonstrated superiority over current pharmacotherapies. Prophylactic laxative regimens to prevent non-defecation have been infrequently studied and there is no recent evidence to further inform treatment of established pseudo-obstruction. Further trials of nonpharmacological and pharmacological therapies to treat upper and lower gastrointestinal dysmotility are required and challenges in designing such trials are explored.
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Abstract
PURPOSE OF REVIEW Skeletal muscle wasting during critical illness is the result of disturbed metabolism. No proven effective interventions targeting skeletal muscle mass and function during critical illness currently exist. This review summarizes recent advances regarding the complexity of metabolic factors involved and the challenge of establishing the clinical effects of metabolic interventions targeting the muscle. RECENT FINDINGS Although the catabolic state is limited to the acute phase of critical illness, its subsequent impact on muscle mass and function persists long after ICU discharge. Immobilization, inflammation and disturbed muscle energy and nutrient metabolism are key drivers of muscle protein loss. Current research focuses on the effects of enhanced protein provision, specific substrate delivery and physical exercise. Whilst some interventions have been successful at improving muscle mass, these effects do not always carry over into muscle function or strength. SUMMARY Increased understanding of metabolic derangements during critical illness provides new potential targets for treatment. The potential of dietary protein to attenuate the muscle protein catabolic state has yet to be established in clinical trials. Basic research should focus on ways to further improve the anabolic potential of nutrition by unravelling mechanisms that regulate anabolic and catabolic pathways and energy metabolism.
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Affiliation(s)
- Robert J.J. van Gassel
- Department of Intensive Care Medicine
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, The Netherlands
| | | | - Marcel C.G. van de Poll
- Department of Intensive Care Medicine
- Department of Surgery, Maastricht University Medical Centre and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, The Netherlands
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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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Abstract
PURPOSE OF REVIEW The objective of this review is to describe the impact of protein intake on the outcomes of critically ill patients in the literature published in the preceding 2 years. RECENT FINDINGS Observational studies showed inconsistent results regarding the association of higher protein intake and outcomes of critically ill patients. Randomized controlled trials that directly compared higher versus lower protein intake in ICU patients are scarce, varied considerably in their designs and primary outcomes, and generally had relatively small differences in the amount of delivered protein between the study arms. Systematic reviews of existing studies showed no difference in mortality with higher protein intake. In addition, there is uncertainty regarding high protein provision in the early phase of critical illness. SUMMARY The optimal amount of protein intake in critically ill patients remains largely unclear and is considered a high priority for research. Ongoing clinical trials are likely to provide additional evidence on several important questions including the dose, timing, type of protein and the interaction with caloric intake and exercise.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard - Health Affairs King Abdullah International Medical Research Center College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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45
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van Zanten ARH, De Waele E, Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:368. [PMID: 31752979 PMCID: PMC6873712 DOI: 10.1186/s13054-019-2657-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/22/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge. METHODS This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey. RESULTS Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis. CONCLUSIONS During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a "victim" of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.
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Affiliation(s)
| | - Elisabeth De Waele
- Intensive Care Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Nutrition, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Fetterplace K, Gill BMT, Chapple LAS, Presneill JJ, MacIsaac C, Deane AM. Systematic Review With Meta-Analysis of Patient-Centered Outcomes, Comparing International Guideline-Recommended Enteral Protein Delivery With Usual Care. JPEN J Parenter Enteral Nutr 2019; 44:610-620. [PMID: 31617220 DOI: 10.1002/jpen.1725] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 09/04/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND International guidelines recommend that protein be administered enterally to critically ill patients at doses between 1.2 and 2 g/kg per day Observational data indicate that patients frequently receive less protein. The aim of this systematic review was to evaluate patient-centered outcomes with guideline-recommended enteral protein compared with usual care. METHODS A systematic review was performed of randomized controlled trials including critically ill adult patients provided predominately enteral nutrition with mean protein at ≥1.2 g/kg per day (intervention) and <1.2 g/kg per day (comparator). Random-effects models were applied for outcomes reported in ≥3 trials. RESULTS Of 1375 abstracts, 69 full-text articles were reviewed, and 6 trials meet the inclusion criteria, including 511 patients. The intervention group received a mean (SD) of 1.3 (0.08) g/kg per day, and the comparator group received 0.75 (0.15) g/kg per day protein. Insufficient data were available for meta-analyses on the primary outcome (muscle mass or strength). According to our meta-analyses, mortality at 28 days (5 studies) (risk ratio 0.92 [95% Cl 0.63-1.35], P = .66) and the durations of intensive care unit (6 studies) and hospital admission (4 studies) were similar between the intervention and comparator, with some uncertainty due to sample sizes and heterogeneity. CONCLUSION There are insufficient data to conclude whether protein provision within the current international guideline recommendations improves outcomes. In a limited dataset, enteral protein intakes near the lower level of current recommendations do not appear to reduce admission duration or mortality when compared with usual care in critically ill.
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Affiliation(s)
- Kate Fetterplace
- Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Benjamin M T Gill
- Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Intensive Care Research, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jeffrey J Presneill
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
| | - Christopher MacIsaac
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
| | - Adam M Deane
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
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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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48
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Koekkoek WAC, van Zanten ARH. Primum non nocere in early nutrition therapy during critical illness: Balancing the pros and cons of early very high protein administration. Clin Nutr 2019; 38:1963-1964. [PMID: 31072664 DOI: 10.1016/j.clnu.2019.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 01/03/2023]
Affiliation(s)
- W A C Koekkoek
- Department of Intensive Care Medicine, Department of Internal Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, the Netherlands.
| | - A R H van Zanten
- Head of ICU & Research, Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, the Netherlands.
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Bendavid I, Zusman O, Kagan I, Theilla M, Cohen J, Singer P. Early Administration of Protein in Critically Ill Patients: A Retrospective Cohort Study. Nutrients 2019; 11:E106. [PMID: 30621003 PMCID: PMC6356518 DOI: 10.3390/nu11010106] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 12/29/2022] Open
Abstract
It is currently uncertain whether early administration of protein improves patient outcomes. We examined mortality rates of critically ill patients receiving early compared to late protein administration. This was a retrospective cohort study of mixed ICU patients receiving enteral or parenteral nutritional support. Patients receiving >0.7 g/kg/d protein within the first 3 days were considered the early protein group and those receiving less were considered the late protein group. The latter were subdivided into late-low group (LL) who received a low protein intake (<0.7 g/kg/d) throughout their stay and the late-high group (LH) who received higher doses (>0.7 g/kg/d) of protein following their first 3 days of admission. The outcome measure was all-cause mortality 60 days after admission. Of the 2253 patients included in the study, 371 (36%) in the early group, and 517 (43%) in the late-high group had died (p < 0.001 for difference). In multivariable Cox regression analysis, while controlling for confounders, early protein administration was associated with increased survival (HR 0.83, 95% CI 0.71⁻0.97, p = 0.017). Administration of protein early in the course of critical illness appears to be associated with improved survival in a mixed ICU population, even after adjusting for confounding variables.
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Affiliation(s)
- Itai Bendavid
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
| | - Oren Zusman
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
| | - Ilya Kagan
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
| | - Miriam Theilla
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
- Nursing Department, Steyer School of Health Professions, Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
| | - Jonathan Cohen
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, 49100 Petah Tikva, Israel.
- Sackler School of Medicine, Tel Aviv University, 39040 Tel Aviv, Israel.
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van Zanten ARH. Response to Gunst and Casaer on the letter to the editor "Is the protein intake saturated at doses recommended by the feeding guidelines for critically ill patients?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:330. [PMID: 30514322 PMCID: PMC6280352 DOI: 10.1186/s13054-018-2189-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 01/23/2023]
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