Protein intake and outcome of critically ill patients: analysis of a large international database using piece-wise exponential additive mixed models

Generalized additive mixed model to evaluate the association between ventilatory ratio and mortality in patients: A retrospective cohort study

Previous studies have indicated that a higher ventilatory ratio (VR) is associated with mortality. However, it is unknown whether dynamic changes in VR over time affect the prognosis of critically ill patients. This study aims to investigate the significance of VR during the progression of the disease in critically ill patients. The Medical Information Mart for Intensive Care III database was searched to identify critically ill patients. The primary outcome was 30-day mortality. Multivariable Cox regression was used to elucidate the relationship between the VR and mortality. Finally, we employed a generalized additive mixed model to compare trends in VR over time between survivors and non-survivors. A total of 8024 patients were enrolled. Multivariable Cox regression analysis identified a baseline VR ≥1.89 as an independent risk factor predicting 30-day mortality (hazard ratio: 2.10, 95% confidence interval: 1.89-2.33, P < .001) and 90-day mortality (hazard ratio: 2.18, 95% confidence interval: 1.97-2.41, P < .001) after adjusting for potential confounders. In the subgroup analyses, the observed association between VR and 30-day mortality showed consistent direction across most subgroups. The generalized additive mixed model results highlighted that the difference in VR between survivors and non-survivors increased by an average of 0.01 per day after adjusting for several covariates. In conclusion, VR dynamically mirrors pathophysiological changes in critically ill patients and its escalation is linked to higher mortality rates. Monitoring VR's dynamic shifts might offer more immediate prognostic information, thus aiding in timely interventions and risk stratification.

Characterizing and Predicting Outcomes in Critically Ill Patients Receiving Low or High Protein Doses with Moderate Energy Support: A Retrospective Study

BACKGROUND

Finding the best energy and protein dose and timing for critically ill patients remains challenging. Distinct populations may react differently to protein load. This study aimed to characterize and predict outcomes of critically ill patients who received moderate energy and high or low protein doses during their stay in the intensive care unit (ICU).

METHODS

The cohort included 646 adult patients (70% men and 30% women) hospitalized in Beilinson Hospital ICU (Petah Tikva, Israel) for over 5 days between 2011 and 2018. Patients received 10-20 kcal/kg/day and were classified into two groups: low (LP) and high (HP) protein support (≤1 g/kg/day vs. >1 g/kg/day), the LP group comprising 531 patients (82%) and the HP group 115 patients (18%). Multiple logistic regression was used to describe associations between patients' characteristics and 90-day survival in the LP and HP groups.

RESULTS

Among LP, increased age, APACHE II, and receiving supplemental parenteral nutrition (SPN) were associated with decreased survival (OR = 0.986, 95% CI [0.973, 0.999]; OR = 0.915, 95% CI [0.886, 0.944], OR = 0.579, 95% CI [0.366, 0.917]). Trauma admission was associated with increased survival (OR = 1.826, 95% CI [1.001, 3.329]). Among HP, increased age was associated with decreased survival (OR = 0.956, 95% CI [0.924, 0.998]). Higher BMI was associated with improved survival (OR = 1.137, 95% CI [1.028, 1.258]). Likewise, in the HP group, the BMI of elderly survivors was higher compared to non-survivors (27.1 ± 6.2 vs. 24.7 ± 4.8, t (113) = 2.3, p < 0.05).

CONCLUSIONS

Our results show that in patients with moderate energy support and low protein administration, survivors were younger, with a lower APACHE II score, mainly suffering from trauma and without renal failure. In the patients receiving high protein support, younger patients with a high BMI not suffering from sepsis were more likely to survive. We suggest confirming these findings with prospective RCTs.

Comparison of two isocaloric parenteral nutrition regimens with different protein content - A propensity-score matched comparative study

Introduction

Objective: this study aimed to assess the effects of two isocaloric parenteral nutrition (PN) regimens with different protein content and non-protein calorie to nitrogen ratio (NPCNR) on the evolution of nutritional parameters and outcomes in adult inpatients. Methods: this was a retrospective quasi-experimental study performed in a 400-bed tertiary hospital. Adult inpatients were initially eligible if they had received ≥ 4 days of PN with NPCNR ≥ 100 or ≤ 90 in a period of three years. Patients were propensity-score matched to adjust for differences, resulting in two final cohorts: Cohort "Medium-P" included patients receiving PN with NCPCNR ≥ 100 and cohort "High-P", receiving PN with NCPCNR ≤ 90. The main variables were differences in plasma albumin, prealbumin, cholesterol, and lymphocyte count, days requiring PN, length of stay, and mortality at 90 days. Results: 202 patients were finally recruited and divided into the two equal cohorts. Patients were mainly male (122; 60.4 %), surgical (149; 73.8 %), critically ill (100; 49.5 %), with high nutritional risk (141; 69.8 %) and with a neoplasm (145; 71.8 %). PN provided 25 kcal/kg/day, but protein intake was 0.25 g/kg/day higher in the "High-P" cohort. Baseline characteristics and biochemistry were not different between the two cohorts. The "High-P" cohort presented a smaller difference at the end of PN for lymphocytes, more days with hyperglycaemia, and more days requiring PN. The rest of variables did not differ. Conclusions: high doses of protein (lower NPCNR) did not present advantages compared to medium doses of protein (higher NPCNR) when providing isocaloric PN in adult inpatients.

Effect of high versus standard protein provision on functional recovery in people with critical illness (PRECISe): an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in Belgium and the Netherlands

BACKGROUND

Increased protein provision might ameliorate muscle wasting and improve long-term outcomes in critically ill patients. The aim of the PRECISe trial was to assess whether higher enteral protein provision (ie, 2·0 g/kg per day) would improve health-related quality of life and functional outcomes in critically ill patients who were mechanically ventilated compared with standard enteral protein provision (ie, 1·3 g/kg per day).

METHODS

The PRECISe trial was an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in five Dutch hospitals and five Belgian hospitals. Inclusion criteria were initiation of invasive mechanical ventilation within 24 h of intensive care unit (ICU) admission and an expected duration of invasive ventilation of 3 days or longer. Exclusion criteria were contraindications for enteral nutrition, moribund condition, BMI less than 18 kg/m2, kidney failure with a no dialysis code, or hepatic encephalopathy. Patients were randomly assigned to one of four randomisation labels, corresponding with two study groups (ie, standard or high protein; two labels per group) in a 1:1:1:1 ratio through an interactive web-response system. Randomisation was done via random permuted-block randomisation in varying block sizes of eight and 12, stratified by centre. Participants, care providers, investigators, outcome assessors, data analysts, and the independent data safety monitoring board were all blinded to group allocation. Patients received isocaloric enteral feeds that contained 1·3 kcal/mL and 0·06 g of protein/mL (ie, standard protein) or 1·3 kcal/mL and 0·10 g of protein/mL (ie, high protein). The study-nutrition intervention was limited to the time period during the patient's ICU stay in which they required enteral feeding, with a maximum of 90 days. The primary outcome was EuroQoL 5-Dimension 5-level (EQ-5D-5L) health utility score at 30 days, 90 days, and 180 days after randomisation, adjusted for baseline EQ-5D-5L health utility score. This trial was registered with ClinicalTrials.gov (NCT04633421) and is closed to new participants.

FINDINGS

Between Nov 19, 2020, and April 14, 2023, 935 patients were randomly assigned. 335 (35·8%) of 935 patients were female and 600 (64·2%) were male. 465 (49·7%) of 935 were assigned to the standard protein group and 470 (50·3%) were assigned to the high protein group. 430 (92·5%) of 465 patients in the standard protein group and 419 (89·1%) of 470 patients in the high protein group were assessed for the primary outcome. The primary outcome, EQ-5D-5L health utility score during 180 days after randomisation (assessed at 30 days, 90 days, and 180 days), was lower in patients allocated to the high protein group than in those allocated to the standard protein group, with a mean difference of -0·05 (95% CI -0·10 to -0·01; p=0·031). Regarding safety outcomes, the probability of mortality during the entire follow-up was 0·38 (SE 0·02) in the standard protein group and 0·42 (0·02) in the high protein group (hazard ratio 1·14, 95% CI 0·92 to 1·40; p=0·22). There was a higher incidence of symptoms of gastrointestinal intolerance in patients in the high protein group (odds ratio 1·76, 95% CI 1·06 to 2·92; p=0·030). Incidence of other adverse events did not differ between groups.

INTERPRETATION

High enteral protein provision compared with standard enteral protein provision resulted in worse health-related quality of life in critically ill patients and did not improve functional outcomes during 180 days after ICU admission.

FUNDING

Netherlands Organisation for Healthcare Research and Development and Belgian Health Care Knowledge Centre.

Impact of an enteral nutrition protocol in critically ill patients with burn injuries

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).

Relevance of Protein Intake for Weaning in the Mechanically Ventilated Critically Ill: Analysis of a Large International Database

OBJECTIVES

The association between protein intake and the need for mechanical ventilation (MV) is controversial. We aimed to investigate the associations between protein intake and outcomes in ventilated critically ill patients.

DESIGN

Analysis of a subset of a large international point prevalence survey of nutritional practice in ICUs.

SETTING

A total of 785 international ICUs.

PATIENTS

A total of 12,930 patients had been in the ICU for at least 96 hours and required MV by the fourth day after ICU admission at the latest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We modeled associations between the adjusted hazard rate (aHR) of death in patients requiring MV and successful weaning (competing risks), and three categories of protein intake (low: < 0.8 g/kg/d, standard: 0.8-1.2 g/kg/d, high: > 1.2 g/kg/d). We compared five different hypothetical protein diets (an exclusively low protein intake, a standard protein intake given early (days 1-4) or late (days 5-11) after ICU admission, and an early or late high protein intake). There was no evidence that the level of protein intake was associated with time to weaning. However, compared with an exclusively low protein intake, a standard protein intake was associated with a lower hazard of death in MV: minimum aHR 0.60 (95% CI, 0.45-0.80). With an early high intake, there was a trend to a higher risk of death in patients requiring MV: maximum aHR 1.35 (95% CI, 0.99-1.85) compared with a standard diet.

CONCLUSIONS

The duration of MV does not appear to depend on protein intake, whereas mortality in patients requiring MV may be improved by a standard protein intake. Adverse effects of a high protein intake cannot be excluded.

The effects of higher versus lower protein delivery in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

A recent large multicentre trial found no difference in clinical outcomes but identified a possibility of increased mortality rates in patients with acute kidney injury (AKI) receiving higher protein. These alarming findings highlighted the urgent need to conduct an updated systematic review and meta-analysis to inform clinical practice.

METHODS

From personal files, citation searching, and three databases searched up to 29-5-2023, we included randomized controlled trials (RCTs) of adult critically ill patients that compared higher vs lower protein delivery with similar energy delivery between groups and reported clinical and/or patient-centred outcomes. We conducted random-effect meta-analyses and subsequently trial sequential analyses (TSA) to control for type-1 and type-2 errors. The main subgroup analysis investigated studies with and without combined early physical rehabilitation intervention. A subgroup analysis of AKI vs no/not known AKI was also conducted.

RESULTS

Twenty-three RCTs (n = 3303) with protein delivery of 1.49 ± 0.48 vs 0.92 ± 0.30 g/kg/d were included. Higher protein delivery was not associated with overall mortality (risk ratio [RR]: 0.99, 95% confidence interval [CI] 0.88-1.11; I2 = 0%; 21 studies; low certainty) and other clinical outcomes. In 2 small studies, higher protein combined with early physical rehabilitation showed a trend towards improved self-reported quality-of-life physical function measurements at day-90 (standardized mean difference 0.40, 95% CI - 0.04 to 0.84; I2 = 30%). In the AKI subgroup, higher protein delivery significantly increased mortality (RR 1.42, 95% CI 1.11-1.82; I2 = 0%; 3 studies; confirmed by TSA with high certainty, and the number needed to harm is 7). Higher protein delivery also significantly increased serum urea (mean difference 2.31 mmol/L, 95% CI 1.64-2.97; I2 = 0%; 7 studies).

CONCLUSION

Higher, compared with lower protein delivery, does not appear to affect clinical outcomes in general critically ill patients but may increase mortality rates in patients with AKI. Further investigation of the combined early physical rehabilitation intervention in non-AKI patients is warranted.

PROSPERO ID

CRD42023441059.

Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding

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.

How to avoid harm with feeding critically ill patients: a synthesis of viewpoints of a basic scientist, dietitian and intensivist

The optimal feeding strategy in critically ill patients is a matter of debate, with current guidelines recommending different strategies regarding energy and protein targets. Several recent trials have added to the debate and question our previous understanding of the provision of nutrition during critical illness. This narrative review aims to provide a summary of interpretation of recent evidence from the view of basic scientist, critical care dietitian and intensivist, resulting in joined suggestions for both clinical practice and future research. In the most recent randomised controlled trial (RCT), patients receiving 6 versus 25 kcal/kg/day by any route achieved readiness for ICU discharge earlier and had fewer GI complications. A second showed that high protein dosage may be harmful in patients with baseline acute kidney injury and more severe illness. Lastly, a prospective observational study using propensity score matched analysis suggested that early full feeding, especially enteral, compared to delayed feeding is associated with a higher 28-day mortality. Viewpoints from all three professionals point to the agreement that early full feeding is likely harmful, whereas important questions regarding the mechanisms of harm as well as on timing and optimal dose of nutrition for individual patients remain unanswered and warrant future studies. For now, we suggest giving low dose of energy and protein during the first few days in the ICU and apply individualised approach based on assumed metabolic state according to the trajectory of illness thereafter. At the same time, we encourage research to develop better tools to monitor metabolism and the nutritional needs for the individual patient accurately and continuously.

Metabolic Support in Acute Respiratory Distress Syndrome: A Narrative Review

Nutritional support for acute respiratory distress syndrome (ARDS) patients shares metabolic notions common to other critically ill conditions. Nevertheless, it generates specific concern regarding the primary limitation of oxygen supply and the complications of carbon dioxide elimination, as well as the significant metabolic alterations due to the body's response to illness. In the present narrative review, after briefly summarizing the pathophysiology of critical illness stress response and patients' metabolic requirements, we focus on describing the characteristics of metabolic and artificial nutrition in patients with acute respiratory failure. In patients with ARDS, several aspects of metabolism assume special importance. The physiological effects of substrate metabolism are described for this setting, particularly regarding energy consumption, diet-induced thermogenesis, and the price of their clearance, transformation, and storage. Moreover, we review the possible direct effects of macronutrients on lung tissue viability during ARDS. Finally, we summarize the noteworthy characteristics of metabolic control in critically ill patients with ARDS and offer a suggestion as to the ideal methods of metabolic support for this problem.

Current insights in ICU nutrition: tailored nutrition

PURPOSE OF REVIEW

To summarize recent research on critical care nutrition focusing on the optimal composition, timing, and monitoring of enteral feeding strategies for (post)-ICU patients. We provide new insights on energy and protein recommendations, feeding intolerance, and describe nutritional practices for coronavirus disease 2019 ICU patients.

RECENT FINDINGS

The use of indirect calorimetry to establish individual energy requirements for ICU patients is considered the gold standard. The limited research on optimal feeding targets in the early phase of critical illness suggests avoiding overfeeding. Protein provision based upon the absolute lean body mass is rational. Therefore, body composition measurements should be considered. Body impedance analysis and muscle ultrasound seem reliable, affordable, and accessible methods to assess body composition at the bedside. There is inadequate evidence to change our practice of continuous enteral feeding into intermittent feeding. Finally, severe acute respiratory syndrome coronavirus 2 patients are prone to underfeeding due to hypermetabolism and should be closely monitored.

SUMMARY

Nutritional therapy should be adapted to the patient's characteristics, diagnosis, and state of metabolism during ICU stay and convalescence. A personalized nutrition plan may prevent harmful over- or underfeeding and attenuate muscle loss. Despite novel insights, more research is warranted into tailored nutrition strategies during critical illness and convalescence.

Nutrition intake in critically ill patients with coronavirus disease (COVID-19): A nationwide, multicentre, observational study in Argentina

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with coronavirus disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March and October 2020.

INCLUSION CRITERIA

Adult ICU patients>18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48h. Statistical analysis was carried out using IBM-SPSS© 24 programme.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97g/kg/day (CI 0.95-0.99), P<0.001), and lower caloric intake than those who survived (12.94kcal/kg/day (CI 12.48-13.39) vs 16.47kcal/kg/day (CI 16.09-16.8), P<0.001). A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II>18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.

Protein supplementation in critical illness: why, when and how?

PURPOSE OF REVIEW

In critically ill patients, optimal protein provision remains a challenge given the wide range in recommended protein delivery in international guidelines and the lack of robust, high quality evidence. As patients are confronted with poor functional outcomes after admission, often attributed to muscle wasting and persisting for multiple years, there is a pressing need for optimal nutritional strategies in the ICU, particularly including protein. This review will discuss the recent literature with regard to purpose, timing and mode of protein delivery.

RECENT FINDINGS

Recent studies on the effect of dose and timing of protein on clinical and functional outcomes are largely observational in nature and the protein delivery considered as "high" still often only nears the lower end of current recommendations. The majority of trials observed no effect of protein supplementation on mortality, muscle strength or function, though some report attenuation of muscle volume loss, especially when combined with muscle activation. There is no strong evidence that ICU patients should receive supplementation with any specific amino acids.

SUMMARY

Though adequate protein provision is likely important, it is difficult to come to a uniform conclusion regarding dosing and timing due to conflicting results in mostly observational studies as well as different cut-off values for high, moderate and low protein intake. This topic is currently subject to large clinical trials.

Potential benefits of using an energy-dense, high-protein formula enriched with β-hydroxy-β-methylbutyrate, fructo-oligosaccharide, and vitamin D for enteral feeding in the ICU: A pilot case-control study in COVID-19 patients

OBJECTIVES

The aim of this study was to investigate the potential benefits of using an energy-dense, high-protein (HP) formula enriched with β-hydroxy-β-methylbutyrate (HMB), fructo-oligosaccharide (FOS), and vitamin D (VitD) for enteral feeding in the intensive care unit (ICU).

METHODS

This was a nested case-control multicenter study. Mechanically ventilated patients with COVID-19 in whom enteral nutrition was not contraindicated and receiving an energy-dense, HP-HMB-FOS-VitD formula (1.5 kcal/mL; 21.5% of calories from protein; n = 53) were matched (1:1) by age (±1 y), sex, body mass index (±1 kg/m²) and Sequential Organ Failure Assessment score (±1 point) and compared with patients fed with a standard HP, fiber-free formula (1.25-1.3 kcal/mL; 20% of calories from protein; n = 53). The primary end point was daily protein intake (g/kg) on day 4. Protein-calorie intake on day 7, gastrointestinal intolerance, and clinical outcomes were addressed as secondary end points.

RESULTS

The use of a HP-HMB-FOS-VitD formula resulted in higher protein intake on days 4 and 7 (P = 0.006 and P = 0.013, respectively), with similar energy intake but higher provision of calories from enteral nutrition at both times (P <0 .001 and P = 0.017, respectively). Gastrointestinal tolerance was superior, with fewer patients fed with a HP-HMB-FOS-VitD formula reporting at least one symptom of intolerance (55 versus 74%; odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-0.99; P = 0.046) and constipation (38 versus 66%; OR, 0.27; 95% CI, 0.12-0.61; P = 0.002). A lower rate of ICU-acquired infections was also observed (42 versus 72%; OR, 0.29; 95% CI, 0.13-0.65; P = 0.003), although no difference was found in mortality, ICU length of stay, and ventilation-free survival.

CONCLUSIONS

An energy-dense, HP-HMB-FOS-VitD formula provided a more satisfactory protein intake and a higher provision of caloric intake from enteral nutrition than a standard HP formula in mechanically ventilated patients with COVID-19. Lower rates of gastrointestinal intolerance and ICU-acquired infections were also observed.

[Nutrition Intake in Critically Ill Patients with Coronavirus Disease (Covid-19): A Nationwide, Multicentre, Observational Study in Argentina]

INTRODUCTION

In 2020 the pandemic caused by SARS-COV-2 demanded an enormous number of healthcare resources in order to guarantee adequate treatment and support for those patients. This study aims to assess caloric and protein intake and evaluate its associations with relevant clinical outcomes in critically ill with Coronavirus Disease (COVID-19) patients.

METHODS

A nationwide, multicentre prospective observational study including twelve Argentinian intensive care units (ICUs,) was conducted between March-October 2020.

INCLUSION CRITERIA

Adult ICU patients >18 years admitted to the ICU with COVID-19 diagnosis and mechanical ventilation for at least 48hs. Statistical analysis was carried out using IBM-SPSS© 24 program.

RESULTS

One hundred and eighty-five patients were included in the study. Those who died had lower protein intake (0.73 g/kg/day (95% confidence interval (CI) 0.70-0.75 vs 0.97 g/kg/day (CI 0.95-0.99), P <0.001), and lower caloric intake than those who survived (12.94 kcal/kg/day (CI 12.48-13.39) vs 16.47 kcal/kg/day (CI 16.09-16.8), P <0.001).A model was built, and logistic regression showed that factors associated with the probability of achieving caloric and protein intake, were the early start of nutritional support, modified NUTRIC score higher than five points, and undernutrition (Subjective Global Assessment B or C). The patients that underwent mechanical ventilation in a prone position present less caloric and protein intake, similar to those with APACHE II >18.

CONCLUSIONS

Critically ill patients with COVID-19 associated respiratory failure requiring mechanical ventilation who died in ICU had less caloric and protein intake than those who survived. Early start on nutritional support and undernutrition increased the opportunity to achieve protein and caloric goals, whereas the severity of disease and mechanical ventilation in the prone position decreased the chance to reach caloric and protein targets.[[[es]]]RESUMENIntroducción: En 2020, la pandemia provocada por el SARS-COV-2, demandó una enorme cantidad de recursos sanitarios para garantizar el tratamiento y apoyo adecuado a estos pacientes. Este estudio tiene como objetivo evaluar la ingesta de calorías/proteínas y evaluar sus asociaciones con resultados clínicos relevantes en pacientes críticamente enfermos con enfermedad por coronavirus (COVID-19).Métodos: Se realizó un estudio observacional prospectivo multicéntrico a nivel nacional que incluyó 12 unidades de cuidados intensivos (UCI) argentinas entre marzo y octubre de 2020. Criterios de inclusión: pacientes adultos de la UCI > 18 años ingresados en la UCI con diagnóstico de COVID-19 y ventilación mecánica durante al menos 48 horas. El análisis estadístico se realizó mediante el programa IBM-SPSS© 24.

RESULTADOS

En el presente estudio se incluyeron 185 pacientes. Entre los que fallecieron se observó un aporte proteico más bajo (0,73 g/kg/día (intervalo de confianza (IC) del 95 % 0,70-0,75 frente a 0,97 g/kg/día (IC 0,95-0,99), P < 0,001), y menor aporte calórico que los que sobrevivieron (12,94 kcal/kg/día (IC 12,48-13,39) vs 16,47 kcal/kg/día (IC 16,09-16,8), P < 0,001).Se construyó un modelo de regresión logística para analizar qué factores estaban asociados con la probabilidad de lograrlos objetivos calóricos/proteicos. Se observo una mayor probabilidad de lograr dichos objetivos cuando el inicio del soporte nutricional era precoz, el puntaje NUTRIC modificado era superior a 5 puntos y el paciente tenía diagnóstico de desnutrición mediante la Evaluación Global Subjetiva(B o C). Por otra parte, en los pacientes que necesitaron ventilación mecánica en decúbito prono se observó menor aporte calórico y proteico, situación similar en aquellos con APACHE II > 18.

CONCLUSIONES

Los pacientes críticos con insuficiencia respiratoria asociada a la enfermedad por COVID-19 que requerían ventilación mecánica y que fallecieron en la UCI tuvieron una ingesta calórica y proteica menor que los que sobrevivieron. El inicio temprano del soporte nutricional y la desnutrición aumentaron la posibilidad de alcanzar los objetivos calóricos y proteicos, mientras que la gravedad de la enfermedad y la ventilación mecánica en decúbito prono disminuyeron la posibilidad de alcanzar los objetivos calóricos y proteicos.

Prone position, time to reach nutrition target, and energy/protein achievement rate on the seventh day of intensive care unit stay in patients with COVID-19: A cohort study

BACKGROUND

We aimed to evaluate the mean time to reach the energy (EAR) and protein (PAR) achievement rate among patients with coronavirus disease 2019 (COVID-19) who did or did not undergo prone position (PP) therapy in the first week of their stay in the intensive care unit (ICU), and the interaction of these nutrition therapy indicators on the association between PP and clinical outcomes.

METHODS

This cohort study used retrospective data collected from medical records of patients with COVID-19 admitted to the ICU (≥18 years). We collected nutrition data, clinical information, prescription of PP, and its frequency during the first week, and clinical outcomes.

RESULTS

PP therapy was administered to 75.2% of 153 patients (61.5 ± 14.8 years, 57.6% males) during the first week of their ICU stay. Patients who underwent PP reached nutrition therapy goals later (4 [3-6] vs 3 [2-4] days; P = 0.030) and had lower EAR (91.9 ± 25.7 vs 101.6 ± 84.0; P = 0.002) and PAR (88.0 ± 27.7 vs 98.1 ± 13.5; P = 0.009) in comparison to those who did not receive PP. Grouping patients who underwent PP according to the EAR (≥70% or <70%) did not show any differences in the incidence of ICU death, duration of mechanical ventilation, or ICU stay (P > 0.05).

CONCLUSIONS

In this exploratory study, PP was associated with a delayed time to reach the nutrition target and the lowest EAR and estimated protein requirement on the seventh day of ICU stay in patients with COVID-19. Permissive enteral nutrition prescription in patients who underwent PP was not associated with worse clinical outcomes.

Impact of early nutrition and feeding route on clinical outcomes of neurocritically ill patients

Early proper nutritional support is important to critically ill patients. Nutritional support is also associated with clinical outcomes of neurocritically ill patients. We investigate whether early nutrition is associated with clinical outcomes in neurocritically ill patients. This was a retrospective, single-center, observational study including neurosurgical patients who were admitted to the intensive care unit (ICU) from January 2013 to December 2019. Patients who started enteral nutrition or parenteral nutrition within 72 hours after ICU admission were defined as the early nutrition group. The primary endpoint was in-hospital mortality. The secondary endpoint was an infectious complication. Propensity score matching (PSM) and propensity score weighting overlap weights (PSOW) were used to control selection bias and confounding factors. Among 1,353 patients, early nutrition was performed in 384 (28.4%) patients: 152 (11.2%) early enteral nutrition (EEN) and 232 (17.1%) early parenteral nutrition (EPN). In the overall study population, the rate of in-hospital mortality was higher in patients with late nutrition than in those with early nutrition (P<0.001). However, there was no significant difference in in-hospital mortality and infectious complications incidence between the late and the early nutrition groups in the PSM and PSOW adjusted population (all P>0.05). In the overall study population, EEN patients had a low rate of in-hospital mortality and infectious complications compared with those with EPN and late nutrition (P<0.001 and P = 0.001, respectively). In the multivariable analysis of the overall, PSM adjusted, and PSOW adjusted population, there was no significant association between early nutrition and in-hospital mortality and infectious complications (all P>0.05), but EEN was significantly associated with in-hospital mortality and infectious complications (all P<0.05). Eventually, early enteral nutrition may reduce the risk of in-hospital mortality and infectious complications in neurocritically ill patients.

Time-varying intensity of oxygen exposure is associated with mortality in critically ill patients with mechanical ventilation

BACKGROUND

There is no consensus exists regarding the association between oxygen exposure (arterial oxygen tension or fraction of inspired oxygen) and outcomes for patients with mechanical ventilation. Additionally, whether the association remains persistent over time is unknown. We aimed to explore the association between exposure to different intensities of oxygen exposure over time and 28-day mortality in patients with mechanical ventilation.

METHODS

We obtained data from the Medical Information Mart for Intensive Care IV (MIMIC-IV), which included adult (≥ 18 years) patients who received invasive mechanical ventilation for at least 48 h. We excluded patients who received extracorporeal membrane oxygenation (ECMO) or who initiated ventilation more than 24 h after ICU admission. The primary outcome was 28-day mortality. Piece-wise exponential additive mixed models were employed to estimate the strength of associations over time.

RESULTS

A total of 7784 patients were included in the final analysis. Patients had a median duration of invasive mechanical ventilation of 8.1 days (IQR: 3.8-28 days), and the overall 28-day mortality rate was 26.3%. After adjustment for baseline and time-dependent confounders, both daily time-weighted average (TWA) arterial oxygen tension (PaO₂) and fraction of inspired oxygen (FiO₂) were associated with increased 28-day mortality, and the strength of the association manifested predominantly in the early-middle course of illness. A significant increase in the hazard of death was found to be associated with daily exposure to TWA-PaO₂ ≥ 120 mmHg (Hazard ratio 1.166, 95% CI 1.059-1.284) or TWA-FiO₂ ≥ 0.5 (Hazard ratio 1.496, 95% CI 1.363-1.641) during the entire course. A cumulative effect of harmful exposure (TWA-PaO₂ ≥ 120 mmHg or TWA-FiO₂ ≥ 0.5) was also observed.

CONCLUSION

PaO₂ and FiO₂ should be carefully monitored in patients with mechanical ventilation, especially during the early-middle course after ICU admission. Cumulative exposure to higher intensities of oxygen exposure was associated with an increased risk of death.

Medical nutrition therapy and clinical outcomes in critically ill adults: a European multinational, prospective observational cohort study (EuroPN)

BACKGROUND

Medical nutrition therapy may be associated with clinical outcomes in critically ill patients with prolonged intensive care unit (ICU) stay. We wanted to assess nutrition practices in European intensive care units (ICU) and their importance for clinical outcomes.

METHODS

Prospective multinational cohort study in patients staying in ICU ≥ 5 days with outcome recorded until day 90. Macronutrient intake from enteral and parenteral nutrition and non-nutritional sources during the first 15 days after ICU admission was compared with targets recommended by ESPEN guidelines. We modeled associations between three categories of daily calorie and protein intake (low: < 10 kcal/kg, < 0.8 g/kg; moderate: 10-20 kcal/kg, 0.8-1.2 g/kg, high: > 20 kcal/kg; > 1.2 g/kg) and the time-varying hazard rates of 90-day mortality or successful weaning from invasive mechanical ventilation (IMV).

RESULTS

A total of 1172 patients with median [Q1;Q3] APACHE II score of 18.5 [13.0;26.0] were included, and 24% died within 90 days. Median length of ICU stay was 10.0 [7.0;16.0] days, and 74% of patients could be weaned from invasive mechanical ventilation. Patients reached on average 83% [59;107] and 65% [41;91] of ESPEN calorie and protein recommended targets, respectively. Whereas specific reasons for ICU admission (especially respiratory diseases requiring IMV) were associated with higher intakes (estimate 2.43 [95% CI: 1.60;3.25] for calorie intake, 0.14 [0.09;0.20] for protein intake), a lack of nutrition on the preceding day was associated with lower calorie and protein intakes (- 2.74 [- 3.28; - 2.21] and - 0.12 [- 0.15; - 0.09], respectively). Compared to a lower intake, a daily moderate intake was associated with higher probability of successful weaning (for calories: maximum HR 4.59 [95% CI: 1.5;14.09] on day 12; for protein: maximum HR 2.60 [1.09;6.23] on day 12), and with a lower hazard of death (for calories only: minimum HR 0.15, [0.05;0.39] on day 19). There was no evidence that a high calorie or protein intake was associated with further outcome improvements.

CONCLUSIONS

Calorie intake was mainly provided according to the targets recommended by the active ESPEN guideline, but protein intake was lower. In patients staying in ICU ≥ 5 days, early moderate daily calorie and protein intakes were associated with improved clinical outcomes. Trial registration NCT04143503 , registered on October 25, 2019.