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Wang L, Chang L, Zhang R, Li K, Wang Y, Chen W, Feng X, Sun M, Wang Q, Lu CD, Zeng J, Jiang H. Optimize individualized energy delivery for septic patients using predictive deep learning models. Asia Pac J Clin Nutr 2024; 33:348-361. [PMID: 38965722 PMCID: PMC11389806 DOI: 10.6133/apjcn.202409_33(3).0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND OBJECTIVES We aim to establish deep learning models to optimize the individualized energy delivery for septic patients. METHODS AND STUDY DESIGN We conducted a study of adult septic patients in ICU, collecting 47 indicators for 14 days. We filtered out nutrition-related features and divided the data into datasets according to the three metabolic phases proposed by ESPEN: acute early, acute late, and rehabilitation. We then established optimal energy target models for each phase using deep learning and conducted external validation. RESULTS A total of 179 patients in training dataset and 98 patients in external validation dataset were included in this study, and total data size was 3115 elements. The age, weight and BMI of the patients were 63.05 (95%CI 60.42-65.68), 61.31(95%CI 59.62-63.00) and 22.70 (95%CI 22.21-23.19), respectively. And 26.0% (72) of the patients were female. The models indicated that the optimal energy targets in the three phases were 900kcal/d, 2300kcal/d, and 2000kcal/d, respectively. Excessive energy intake increased mortality rapidly in the early period of the acute phase. Insufficient energy in the late period of the acute phase significantly raised the mortality as well. For the rehabilitation phase, too much or too little energy delivery were both associated with elevated death risk. CONCLUSIONS Our study established time-series prediction models for septic patients to optimize energy delivery in the ICU. We recommended permissive underfeeding only in the early acute phase. Later, increased energy intake may improve survival and settle energy debts caused by underfeeding.
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Affiliation(s)
- Lu Wang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Chang
- Department of Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ruipeng Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Kexun Li
- Department of Emergency Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu Wang
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Chen
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuanlin Feng
- Department of Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Mingwei Sun
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qi Wang
- Department of Mathematics, University of South Carolina, Columbia, SC, USA
| | - Charles Damien Lu
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Emergency Intensive Care Unit, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Emergency Surgery, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Doola R, Dupuis C, Preiser JC. Nutrition support, carbohydrate feeding and insulin sensitivity in the critically ill patient: a complex relationship. Curr Opin Clin Nutr Metab Care 2024; 27:350-354. [PMID: 38712890 DOI: 10.1097/mco.0000000000001039] [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: 05/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent studies that highlight the complex relationship between nutrition, carbohydrate, insulin provision and glycaemic control in the critically ill patient population. RECENT FINDINGS Results of observational studies concur to support early hypoglycaemia and persisting hyperglycaemia as life-threatening events. In contrast, interventional studies indicate that early macronutrient restriction appears to reduce the benefits related to insulin therapy. This restriction is however associated with improved outcomes in itself. The potential role of modified enteral solutions as an adjunctive treatment to attenuate hyperglycaemia warrants further research. The selection of a therapeutic modality may also differ according to the characteristics of the setting, such as the nurse-to-patient ratio, the type and accuracy of meters, including near-continuous glucose monitoring and the availability of computer-guided protocols. SUMMARY There appears to be significant interplay between nutrition, including carbohydrate provision, blood glucose control and clinical outcomes. Individualized care is probably needed to define the optimal glucose target and nutritional intervention. This can differ according to the preexistence of chronic hyperglycaemia, the timing from the onset of critical illness and the clinical condition itself.
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Affiliation(s)
- Ra'eesa Doola
- Centre for Functioning and Health Research, Metro South Health
- Nutrition and Dietetics, Princess Alexandra Hospital, Metro South Health
- PA-Southside Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Claire Dupuis
- Service de Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Charles Preiser
- Service de médecine interne, HUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Shen Y, Qiu B, Ge Q, Hu L, Cong Z, Wu Y. Effect of early enteral nutrition on short-term outcomes and survival in patients in the cardiothoracic intensive care unit: An inverse probability weighted retrospective study. Nutrition 2024; 119:112328. [PMID: 38237353 DOI: 10.1016/j.nut.2023.112328] [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: 09/28/2023] [Revised: 11/15/2023] [Accepted: 12/09/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVES The merits of early enteral nutrition (EEN) in patients in the cardiothoracic intensive care unit (CTICU) remain unclear. This retrospective study aimed to address this issue. METHODS We analyzed data from the MIMIC IV v2.0 database, including patients with a CTICU stay of ≥4 d. Patients were divided into early and delayed enteral nutrition (EN) groups. Differences in baseline data were corrected using an inverse probability weighting (IPW) approach. Generalized linear models (GLMs) were used to compare trends over time between groups, and survival effects were evaluated with weighted logistic and Cox regression, supplemented by weighted Kaplan-Meier curves. Subgroup analysis facilitated the exploration of potential interactions. RESULTS The study included 720 CTICU patients. Following IPW, all baseline variables were balanced. EEN led to shorter hospital and CTICU stays, lower incidence of respiratory and blood infections, and reduced total insulin usage in the first week of CTICU admission, albeit with an increased total gastric residual volume. Mortality risk between the groups did not significantly differ at 28 d or at 1 y. Excessive early energy and protein intake elevated the risk of 28-d mortality, but the relationship may not be linear. Overweight patients or those with fewer comorbidities had a higher mortality risk with EEN. CONCLUSIONS EEN may improve short-term outcomes in CTICU patients without a clear survival benefit. Early high caloric and protein intake could lead to adverse outcomes, suggesting a careful evaluation for initiating EN in specific patients.
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Affiliation(s)
- Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China; Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Bingmei Qiu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jiangsu, China
| | - Qiyue Ge
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China
| | - Liwen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Zhuangzhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Jiangsu, China
| | - Yuheng Wu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Jiangsu, China.
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Yue HY, Peng W, Zeng J, Zhang Y, Wang Y, Jiang H. Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis. J Intensive Care 2024; 12:4. [PMID: 38254228 PMCID: PMC10804832 DOI: 10.1186/s40560-024-00717-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU). METHODS Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed. RESULTS Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%). CONCLUSIONS Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.
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Affiliation(s)
- Han-Yang Yue
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Wei Peng
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yang Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yu Wang
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan Wang Fu Jing, Dong Cheng District, Beijing, 100730, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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