Malnutrition in critically ill patients in intensive care units

Role of platelet to albumin ratio for predicting persistent acute kidney injury in patients admitted to the intensive care unit

BACKGROUND

The aim of this study was to investigate the prognostic role of platelet to albumin ratio (PAR) and in persistent acute kidney injury (pAKI) of patients admitted to the intensive care unit (ICU).

METHODS

We involved pAKI patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and eICU Collaborative Research Database (eICU-CRD). Receiver operating curve (ROC) analysis was performed to evaluate the optimal cut-off PAR.

RESULTS

A total of 7,646 patients were finally included in the present study. The optimal cut-off value of PAR was 7.2. The high-PAR group was associated with pAKI (hazard ratio [HR]: 3.25, 95% CI: 2.85-3.72, P < 0.001). We also performed this in the validation cohort, the results further confirmed that the high-PAR group was associated with pAKI (HR: 2.24, 95% CI: 1.86-2.71, P < 0.001). The PAR exhibited good pAKI predictive abilities in the original cohort (C-index: 0.726, 95%CI: 0.714-0.739) and in the validation cohort (C-index: 0.744, 95%CI:0.722-0.766) Moreover, as a systemic inflammatory indicator, PAR depicted better predictive ability compared to other systemic inflammatory indicators.

CONCLUSION

The present study manifested that elevated PAR could predicts pAKI in patients admitted to ICU. PAR may be an easily obtained and useful biomarker to clinicians for the early identification of pAKI.

The effects of synbiotic supplementation on enteral feeding tolerance, protein homeostasis, and muscle wasting of critically ill adult patients: a randomized controlled trial

Background

Enteral feeding intolerance, energy-protein malnutrition, and muscle wasting are common conditions in the critical care setting. The primary aim of this study was to investigate the effect of synbiotic supplementation on enteral feed volume, energy and protein homeostasis, and muscle mass maintenance in critically ill adult patients.

Methods

A consecutive of 42 patients admitted to the Edalatian Medical ICU, requiring enteral nutrition (EN), were prospectively randomized to receive the synbiotic capsule (containing a combination of Lactobacillus, Bifidobacterium, Streptococcus, and fructooligosaccharides) or placebo (21 patients in each group) for a maximum of 14 days. Enteral intolerance and energy homeostasis were evaluated on a daily basis. Nitrogen balance and 24-h urine creatinine excretion were recorded on days 1 and 14. Mid-arm circumference was recorded every 3 days.

Results

Mean EN volume, energy, and protein intake per day were 962.5 ± 533.82 ml, 770 ± 427.05 kcal, and 38.5 ± 21.35 g (fourth day) vs. 590 ± 321.1 ml, 472 ± 256.81 kcal, and 23.6 ± 12.84 g (first day) in the synbiotic group (p < 0.05). Changes in the placebo group were not statistically significant. On day 1, nitrogen balance (NB) was − 19.84 ± 8.03 in the synbiotic vs. − 10.99 ± 9.12 in the placebo group (p = 0.003). On day 14, NB was − 14.18 ± 13.05 in the synbiotic and − 9.59 ± 7.71 in the placebo group (p = 0.41). Mid-arm circumference (MAC), 24-h urine creatinine, and creatinine-height index were almost steady in the synbiotic group, while they decreased in the placebo group.

Conclusion

Overall, it can be concluded that enteral nutrition supplemented with synbiotics has no statistically significant effect on energy and protein homeostasis and muscle mass maintenance of critically ill patients on day 14, but it can increase enteral feed volume and energy and protein intake during the first 4 days of ICU admission.

Trial registration

The trial protocol has been approved in Iranian Registry of Clinical Trials on March 17, 2019. The registration reference is IRCT20190227042857N1.

Effects of synbiotic supplementation on energy and macronutrients homeostasis and muscle wasting of critical care patients: study protocol and a review of previous studies

BACKGROUND

An extreme and persistent dysbiosis occurs among critically ill patients, regardless of the heterogeneity of disease. Dysbiosis in critically ill patients may make them prone to hospital-acquired infections, sepsis, multi-organ failure (MOF), energy homeostasis disturbance, muscle wasting, and cachexia. Modulation of gut microbiota through synbiotics can be considered as a potential treatment for muscle wasting and macronutrient homeostasis disturbances.

METHODS

This is a prospective, single-center, double-blind, parallel randomized controlled trial with the aim to evaluate the effects of synbiotic supplementation on energy and macronutrient homeostasis and muscle wasting in critically ill patients. A total of 40 hemodynamically stable, adult, critically ill patients who receive enteral nutrition via a nasogasteric tube (NGT) in the 24-48 h after admission to critical care will be included in this study. Eligible patients will be randomly assigned to receive Lactocare (ZistTakhmir) capsules 500 mg every 12 h or a placebo capsule, which contains only the sterile maize starch and is similar to synbiotic capsules for 14 days. The synbiotic and placebo capsules will be given through the nasogastric tube, separately from gavage, after feeding.

DISCUSSION

Gut microbiota modulation through synbiotics is proposed to improve clinical prognosis and reduce infectious complications, ventilator dependency, and length of ICU stay by improving energy and macronutrient homeostasis and reducing muscle protein catabolism.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials, IRCT20190227042857N1. Registered on 17 March 2019.

Disorders of nutritional status in sepsis - facts and myths

The problem of diagnosing nutritional status disorders in septic patients remains unresolved. This is associated with the necessity of the introduction of newer and newer methods of assessing nutritional status, often requiring precise and expensive equipment as well as employment of professionals in this field in hospital wards, primarily including intensive care units (ICU). Methods that have been applied thus far for assessing nutritional status, also used in severely ill septic patients, have little impact on improving treatment results. This is due to the high dynamics of changes in nutritional status in these patients, healing process variability in individual patients, and the “mismatch” of methods for assessing nutritional status in relation to the patient’s clinical status. The diagnostic value of the traditional methods of assessing nutritional status, i.e. anthropometric analysis and selected laboratory tests, as markers of nutritional status disorders in septic patients, is still debatable. There is still no precise method that could become the “gold standard” allowing for early identification of malnutrition in these group of patients. Phase angle, bioelectrical impedance vector analysis (BIVA), and the “illness marker”, obtained directly from the resistance, reactance, and impedance, can be used as prognostic or nutritional indices in severely ill septic patients, but the intensity of research on this subject needs to be increased. Detailed assessment of nutritional status should include tests of selected inflammation markers (including TLC, HMGB1, IL-6, IL-10, IL-1ra, sTNFRI).

Lymphocyte count as a sign of immunoparalysis and its correlation with nutritional status in pediatric intensive care patients with sepsis: A pilot study

OBJECTIVES:

Developing malnutrition during hospitalization is well recognized worldwide, and children are at a relatively higher risk for malnutrition than adults. Malnutrition can lead to immune dysfunction, which is associated with a higher mortality rate due to sepsis, the most frequent cause of death in pediatric intensive care units (PICUs). The aim of this study was to investigate whether malnourished patients are more likely to have relative or absolute lymphopenia and, consequently, worse prognoses.

METHODS:

We enrolled 14 consecutive patients with sepsis whose legal representatives provided written informed consent. Patients were classified as normal or malnourished based on anthropometric measurements. As an additional evaluation of nutritional status, serum albumin and zinc were measured on the 1st and 7th days of hospitalization. Lymphocyte count was also measured on the 1st and 7th days. Clinicaltrials.gov: NCT02698683.

RESULTS:

Malnutrition prevalence rates were 33.3% and 42.8% based on weight and height, respectively. Laboratory analyses revealed a reduction of serum albumin in 100% of patients and reduction of zinc in 93.3% of patients. A total of 35% of patients had fewer than 500 lymphocytes/mm3 on their first day in the PICU. Lymphocyte counts and zinc concentrations significantly increased during hospitalization.

CONCLUSIONS:

Nutritional evaluations, including anthropometric measurements, were not correlated with lymphocyte counts. Lymphocyte counts concomitantly increased with zinc levels, suggesting that micronutrient supplementation benefits patients with sepsis.

Enteral nutritional support of the critically ill older adult

Nutrition continues to be a concern for the older adult in the intensive care setting despite widespread knowledge of the benefits of adequate nutrition and existing evidence-based protocols. The incidence of malnutrition in hospitalized patients ranges between 22% and 43% with the highest probability of occurrence, 50% or more, in the intensive care unit patient. The deleterious effects of malnutrition for the critically ill older adult are described with suggested and accepted screening tools for existing or acquired malnutrition. A discussion of early oral and enteral feeding interventions and strategies for overcoming barriers is explored. Enteral feeding complications are delineated, and perceived barriers or risks are disputed. This paper concludes with suggestions for future research and a definitive role for advanced nursing nutrition champions.

Increased Resting Energy Expenditure after Endovascular Coiling for Subarachnoid Hemorrhage

BACKGROUND

Appropriate nutritional care from the acute stage is essential for improved functional outcomes and reduced mortality in patients with subarachnoid hemorrhage (SAH). Although endovascular coiling is increasingly being used as an alternative to neurosurgical clipping and craniotomy for ruptured aneurysms, the resting energy expenditure (REE) of patients treated with this new technique has not been systemically evaluated.

METHODS

We measured REE values by indirect calorimetry in 12 SAH patients treated with endovascular coiling. We averaged the REE measurements obtained on days 1 and 7 after endovascular coiling, and then we statistically compared the mean REE values with those in 30 patients with acute cerebral infarction (ACI) by the Wilcoxon rank-sum test (P <.05). Next, we calculated the ratio of measured REE values to the values estimated using the Harris-Benedict equation to adjust for demographic differences in sex, weight, height, and age between the groups.

RESULTS

The ratios were significantly higher in SAH patients (median value, 1.12; interquartile range, 1.05-1.23) than in ACI patients (median value, 1.02; interquartile range, .97-1.09).

CONCLUSIONS

Because endovascular coiling is less invasive than neurosurgical clipping, the observed increase in REE was attributed to metabolic changes after SAH. To provide optimal nutritional care to SAH patients from the acute stage, clinicians should be aware of this change in REE.

Effects of malnutrition with or without eicosapentaenoic acid on proteolytic pathways in diaphragm

Attenuation of muscle wasting has been reported with eicosapentaenoic acid (EPA) use in cachectic states. Pathways mediating muscle proteolysis with severe short-term nutritional deprivation (ND)±EPA were evaluated, including diaphragm fiber-specific cross-sectional areas, mRNA (real-time PCR) and protein expression (Western blot). Rats were divided into three groups: (1) free-eating controls, (2) ND and (3) ND+EPA. ND significantly influenced multiple proteolytic pathways. EPA significantly reduced mRNA abundances for most genes to control levels with ND. However, discordant muscle protein expression of many genes was noted with the use of EPA, as protein levels failed to fall. EPA had no impact on diaphragm muscle atrophy, despite the impressive mRNA and some protein results. We conclude that EPA does not attenuate diaphragm muscle atrophy with severe levels of ND. Postulated mechanisms include reduction in muscle protein synthesis and persistent ongoing stimuli for proteolysis. Our study provides unique data on proteolytic signals with ND and has important implications for future studies using EPA.

The pathophysiology of emphysema: considerations for critical care nursing practice

Emphysema is caused by exposure to cigarette smoking as well as alpha(1)-antitrypsin deficiency. It has been estimated to cost the National Health Service (NHS) in excess of 800 million pounds per year in related health care costs. The challenges for Critical Care nurses are those associated with dynamic hyperinflation, Auto-PEEP, malnutrition and the weaning from invasive and non-invasive mechanical ventilation. In this paper we consider the impact of the pathophysiology of emphysema, its effects on other body systems as well as the impact acute exacerbations have when patients are admitted to the Intensive Care Unit.

Selective induction of inducible nitric oxide synthase in pancreatic islet of rat after an intravenous glucose or intralipid challenge

OBJECTIVE

Constant exposure of pancreatic islets to high levels of glucose or free fatty acids can lead to irreversible beta-cell dysfunction, a process referred to as glucotoxicity or lipotoxicity, respectively. In this context a role for nitric oxide generated by pancreatic islet has been suggested. The present investigation examined whether the route of glucose administration, i.e., given orally (OG) or infused intravenously (IVG), could have any effect on the expression and activity of inducible nitric oxide synthase (iNOS) in pancreatic islets.

METHODS

Rats were infused with glucose (50%) or Intralipid intravenously for 24 h or given glucose orally. A freely fed control group (FF) was also included. At 24 h rats were killed and blood samples were drawn for analysis of plasma insulin, glucagon, and glucose. Pancreatic islets were harvested from each animal and investigated for the occurrence of iNOS by the use of confocal microscopy, western blot, and high-performance liquid chromatographic analysis. The effect of intravenously infused glucose was then compared with the effect of an intravenous infusion of Intralipid (IL).

RESULTS

Plasma insulin levels were markedly decreased after 24 h of infusion of glucose (IVG group) or Intralipid (IL group) compared with the FF or OG group. Plasma glucagon and glucose levels were markedly increased in the IVG group, whereas both parameters were decreased in the IL group. No significant differences in plasma insulin, glucagon, or glucose were found between the OG and FF groups. Immunocytochemical (confocal microscopy), western blot, and biochemical (high-performance liquid chromatographic) analyses showed that a sustained increase in plasma level of glucose or free fatty acids by an intravenous infusion of either nutrient for 24 h resulted in a marked expression and activity of iNOS in pancreatic islets. No sign of iNOS expression could, however, be detected in the islets of FF control or OG rats.

CONCLUSION

The data suggest that impaired beta-cell function found after 24 h of an intravenous infusion of glucose or Intralipid might be mediated, at least in part, by the induction of iNOS in pancreatic islets. This may subsequently result in an exclusive production of nitric oxide, which is deleterious for beta-cells.

Effect of severe short-term malnutrition on diaphragm muscle signal transduction pathways influencing protein turnover

The aim of this study was to evaluate the effect of nutritional deprivation (ND) on signal transduction pathways influencing the translational apparatus in the diaphragm muscle. Male rats were divided into two groups: 1) 20% of usual food intake for 4 days (ND) with water provided at libitum and 2) free-eating control (Ctl). Total protein and RNA were extracted from the diaphragm. Insulin-like growth factor I mRNA was analyzed by RT-PCR. Protein analyses of key cytoplasmic proteins for three signaling pathways deemed important in influencing protein turnover [phosphatidylinositol 3-kinase- Akt-mammalian target of rapamycin, P13K/Akt/glycogen synthase kinase (GSK)-3, and MAPK-ERK] were performed by Western blot. Body weight decreased 30% in ND and increased 17% in Ctl animals. Diaphragm mass decreased 29% in ND animals. Muscle insulin-like growth factor I mRNA abundance was reduced 63% in ND animals. ND resulted in a 55% reduction in phosphorylated (Ser473) Akt. Phosphorylation of mammalian target of rapamycin at Ser2448 was reduced by 85% in ND animals. Downstream effectors important in translation initiation were also affected by ND. Phosphorylated (Thr389) 70-kDa ribosomal protein S6 kinase was significantly reduced (35%) by ND. ND also resulted in significant dephosphorylation of the translational repressor initiation factor 4E-binding protein 1. Phosphorylation of GSK-3alpha (Ser21) and GSK-3beta (Ser9) was increased 55 and 45%, respectively, with ND. Phosphorylation of ERK1 (Thr202) and ERK2 (Tyr204), p44 and p42, respectively, was reduced 64 and 55%, respectively, with ND. Total protein concentration for all signaling intermediates of the three pathways was preserved. We conclude that short-term ND altered the phosphorylation states of key proteins of several pathways involved in protein turnover. This forms the framework for future studies aimed at identifying therapeutic targets in the management of short-term nutritionally induced cachectic states.

Implementing clinical guidelines for nutrition in a neurosurgical intensive care unit

Patients in neurosurgical intensive care have individual needs concerning nutrition because of their conditions. An important therapeutic goal is to prevent the development of malnutrition as it contributes to an increase in mortality and enhances the risk of complications in these patients. The health-care team has a mutual responsibility for this, although it is a complex task and a correct assessment of patients' nutritional needs is vital. Multidisciplinary clinical guidelines focused on nutrition might help the health-care staff in decision-making and allowing individualized treatment for patients. The aim of this study was to evaluate the implementation and use of such a guideline. The results show that the guideline is used in varying degrees by the health-care team. Areas that focused on more practical aspects of nutritional support seemed to have a unified approach, whereas areas on nutritional assessment and routine nutrition orders demonstrated both a lack of knowledge and unclear role responsibilities. The results reveal how different professional groups in health care perceive the implementation of a clinical guideline. Some areas need further clarification, there needs to be continuing development of nutritional guidelines, and education of staff is needed in order to enhance the nutritional care of patients.

Predicted vs measured energy expenditure in critically ill, underweight patients

A retrospective analysis was conducted to compare 4 energy-prediction equations against measured resting energy expenditure (MREE) determined via indirect calorimetry. Data from a heterogeneous group of 42 critically ill, severely underweight (59.50 +/- 17.30 kg; 77.1 +/- 9.7% ideal body weight [IBW]) male patients were assessed. The Hamwi formula was used to determine IBW. The Harris-Benedict (HB) equation was calculated for patients <90% IBW using both current body weight (CBW) and IBW. Energy needs were also estimated with an Ireton-Jones formula for all mechanically ventilated patients (n = 37). For patients <85% IBW (n = 31), an adjusted body weight was determined ([CBW + IBW]/2) and used in the HB formula. The HB formula using the IBW, CBW, and adjusted body weight was significantly different (p < .05) than MREE. The Ireton-Jones equation was not significantly different (p > .05) from MREE but tended to overestimate energy needs (109.3% +/- 16.8% MREE). Conversely, using the CBW or IBW in the HB underestimated the patient's energy needs; 77.0% +/- 11.6% MREE and 90.9 +/- 16.1% MREE, respectively. For patients <85% IBW, use of the adjusted body weight in the HB represented 84.2% +/- 13.9% MREE. The average caloric need was 31.2 +/- 6.0 kcal/kg CBW. Indirect calorimetry remains the best method of determining a patient's energy needs. Until a large prospective trial is conducted, a combination of prediction equations tempered with clinical judgment and monitoring the appropriateness of the nutrition prescription remains the best approach to quality patient care.

Gastric emptying in mechanically ventilated critically ill patients: effect of neuromuscular blocking agent

OBJECTIVE

To assess gastrointestinal function in critically ill patients receiving muscle relaxant and to test clinical tolerance to enteral nutrition.

DESIGN AND SETTING

Prospective study in an intensive care unit.

PATIENTS

20 critically ill patients requiring sedation with muscle relaxant to obtain adequate mechanical ventilation.

MEASUREMENTS AND RESULTS

Patients were randomly selected to receive infusions of opioid sedation during the first session (session 1) and the same sedation with muscle relaxation (cisatracurium) during the second session (session 2). Gastric emptying was assessed by the paracetamol absorption technique. Following the paracetamol absorption 200 ml enteral feed was given, and the residual gastric volume was measured 1 and 2 h after feeding. The maximum plasma concentration (Cmax) was 14 mg/l (range 5-26) when patients received sedation, and 12 mg/l (range 5-30) when they received muscle relaxant. The target time for reaching the maximum plasma concentration (Tmax) was 30 min (range 20-60) and 35 min (range 20-60), respectively, in sessions 1 and 2. There was no significant difference between the two session as regards Tmax, Cmax, or AUC(0-120). The residual volumes were 110+/-65 ml (H1) and 95+/-76 ml (H2) during session 1 and 125+/-85 ml (H1) and 105+/-90 ml (H2) during session 2.

CONCLUSIONS

Enteral feeding is one of the most effective methods of supporting nutritional needs in the critically ill patient. We conclude that in critically ill patients requiring sedation gastric emptying is not improved by neuromuscular blocking agent.

A case study of holistic wound management in intensive care

Complex wounds that have become contaminated after abdominal surgery can cause a great deal of distress to patients, and the management of such wounds requires an holistic and humanistic approach (Torrance, 1985). This case study aims to address the issues of wound management, involving some of the underlying and surrounding problems - exudate, malodour, nutrition and wound pain - that may be associated with chronic wounds after surgery. Further discussed will be the treatment and use of vacuum-assisted closure (VAC) therapy which was administered to the patient in this study. The clinical environment is an intensive care unit (ICU) within a district general hospital. The critical care nurse is primarily involved in caring for resuscitation of the critically ill patient and wound care is often a long way down the list of priorities; however, wound management is important and must be addressed at part of holistic nursing care.

Nutritional awareness of critically ill surgical high-dependency patients

It has been recognized that malnutrition in hospital is a serious problem that may go undetected. There is growing evidence that early nutritional support in high-risk patients helps reduce postoperative complications; however, malnutrition is often diagnosed only once it is well established. This study showed that, both retrospectively and prospectively; there were no formal nutritional assessments of patients in a high-dependency unit (HDU), that time to feeding was generally within the recommended 5-7 day postoperative period, and that the most common form of supplementary feeding was total parenteral nutrition (TPN). Prospectively, the choice of supplementary feeding was dependent on the type of surgery and the individual patient's condition. Since this study was completed, a dietician has been allocated to the HDU and carries out formal nutritional assessments on a daily basis. Further research is required to assess the impact of the dietician on patient nutrition.