Comparison of Methods for Intravenous Infusion of Fat Emulsion During Extracorporeal Membrane Oxygenation

Nutrition Provision in Children with Heart Disease on Extracorporeal Membrane Oxygenation (ECMO)

Nutrition provision for children with heart disease supported with extracorporeal membrane oxygenation (ECMO) involves nuanced decision making. We examined nutrition provision while on ECMO in the CICU and the relationship between energy and protein adequacy and end organ function as assessed by pediatric sequential organ failure assessment (pSOFA) scores in children with heart disease supported with ECMO. Children (≤ 21 years-old) with congenital or acquired heart disease who received ECMO in the cardiac intensive care unit were included. There were 259 ECMO runs in 252 patients over an 8-year study period (2013-2020). Median energy delivery and adequacy were 26.1 [8.4, 45.9] kcal/kg/day and 58.3 [19.8, 94.6]%, respectively. Median protein delivery and adequacy were 0.98 [0.36, 1.64] g/kg/day and 35.7 [13.4, 60.3]%, respectively. pSOFA increased by a median of four points during the ECMO run. Change in pSOFA score was not associated with energy or protein adequacy (p = 0.46 and p = 0.72, respectively). Higher energy and protein adequacy-from parenteral nutrition-correlated with increased hospital-acquired infections (HAIs, p = 0.031 and p = 0.003, respectively). Achieving nutritional adequacy was dependent on the use of parenteral nutrition. Similar clinical outcomes with regard to end organ function but with an increased incidence of HAIs suggests the need to explore the role of optimal enteral nutrition delivery on ECMO.

Research progress on nutritional support in the neonatal and pediatric populations receiving extracorporeal membrane oxygenation

Nutritional support is crucial for the prognosis of children supported by extracorporeal membrane oxygenation (ECMO). This article discusses the latest research progress and guideline recommendations for nutritional support during ECMO. We summarize the nutritional status and evaluation of ECMO patients, nutritional support methods and timing, trace elements, the impact of continuous renal replacement therapy (CRRT), and energy requirements and algorithms. The article shows that malnutrition is high in ECMO patients compared to other critically ill patients, with nearly one-third of patients experiencing a decrease in nutritional indicators. The timing of the initiation of nutrition is very important for the nutritional status of the child. Early enteral nutrition can improve patient prognosis, which is the most commonly used, with parenteral nutrition as a supplement. However, the proportion of enteral nutrition is relatively low, and a stepwise nutrition algorithm can determine when to initiate early enteral nutrition and parenteral nutrition. Malnourishment during critical illness have been associated with increased morbidity as well as increased mortality. Nutritional status should be evaluated at admission by screening tools. In addition, changes in the levels of several metabolites in vivo, such as blood lipids, carnitine, and thiamine, can also reflect the degree of nutritional deficiency in critically ill children. This article provides a reference for the implementation of nutrition of pediatric ECMO patients and further research on nutritional support.

Nutrition for critically ill children with congenital heart disease

Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.

Intravenous lipid emulsion for the treatment of poisonings in 313 dogs and 100 cats (2016-2020)

Introduction

The aim of this retrospective study was to analyze the effect and potential adverse effects of intravenous lipid emulsion (ILE) in poisoned dogs and cats over a 5 years period.

Methods

Medical records of 313 dogs and 100 cats receiving ILE between 2016-2020 were analyzed for suspected toxicant, clinical signs, ILE dosages and frequency, the effect and adverse effects of ILE, and patient outcome.

Results

Dogs and cats were poisoned with mostly unidentified toxicants (48%), rodenticides (8%), recreational drugs and nuts (7% each) and other toxicants. Clinical signs included neurologic deficits (63%), cardiovascular signs (29%), thermoregulation (21%) or gastrointestinal abnormalities (17%). Treatment with ILE was initiated within a median of 6.0 h (1.0-91.0 h) after poisoning. Dogs and cats received a total amount of median 8.0 mL/kg (1.5-66.6 mL/kg) and 15.8 mL/kg (1.8-69.4 mL/kg) ILE, respectively. A positive effect was observed in 74% of the patients, whereas clinical signs worsened in 4% of the patients after ILE administration. No subjective effect was detected in 22% of the patients. Suspected or possible adverse effects of ILE occurred in 6% of the patients, including neurological signs (temporarily reduced consciousness and ataxia), bradycardia, hyperthermia, vomiting, diarrhea, respiratory distress, worsening of the general behavior, facial swelling, and thrombophlebitis. The overall survival rate was 96%. One dog who potentially experienced adverse events was euthanized.

Conclusion

ILE treatment was successful in most patients but can be associated with adverse effects. Administration of ILE should be carefully selected on an individual basis after weighing the possible benefits against potential adverse effects.

Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges

Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been gradually applied in clinical practice and are beneficial for severe burn patients with refractory respiratory failure or renal dysfunction. However, the literature on ECMO combined with CRRT for the treatment of severe burns is limited. Here, we focus on the current status of ECMO combined with CRRT for the treatment of severe burns and the associated challenges, including the timing of treatment, nutrition support, heparinization and wound management, catheter-related infection and drug dosing in CRRT. With the advancement of medical technology, ECMO combined with CRRT will be further optimized to improve the outcomes of patients with severe burns.

Nutrition Considerations in Neonatal Extracorporeal Life Support

Extracorporeal life support (ECLS) is a life-saving therapy, but neonates who require ECLS have unique nutritional needs and require aggressive, early nutritional support. These critically ill neonates are at increased risk for long-term feeding difficulties, malnutrition, and growth failure with associated increased morbidity and mortality. Unfortunately, few studies specific to this population exist. Clinical guidelines published by the American Society for Parenteral and Enteral Nutrition are specific to this population and available to aid clinicians in appropriate nutrition regimens, but studies to date suggest that nutrition provision varies greatly from center to center and often is inadequate. Though enteral feedings are becoming more common, aggressive parenteral nutrition is still needed to ensure nutrition goals are met, including the goal of increased protein provision. Long-term complications, including the need for tube feedings and growth failure, are common in neonatal ECLS survivors, particularly those with congenital diaphragmatic hernia. Oral aversion with poor feeding and growth failure must be anticipated and recognized early if present. The nutritional implications associated with the development of acute kidney injury, fluid overload, or the use of continuous renal replacement therapy must be recognized. In this state-of-the-art review, we examine aspects of nutrition for neonates receiving ECLS including nutritional requirements, nutrition provision, current practices, long-term outcomes, and special population considerations.

Propofol Safety in Anticoagulated and Nonanticoagulated Patients During Extracorporeal Membrane Oxygenation

Sedation management during extracorporeal membrane oxygenation(ECMO) is a common challenge encountered by treating intensivists. Data about the safety of propofol use during ECMO has been contradictory. We aimed to investigate associated risks of propofol use on oxygenator lifespan and to explore the effect of propofol use on oxygenator membranes when therapeutic anticoagulation was omitted. Adult respiratory ECMO patients who received propofol were retrospectively compared with those who did not, and outcomes were assessed by means of duration of oxygenator functionality before requiring an exchange, and number of exchanges during propofol use and/or ECMO support. Out of the 63patients included in the analysis, 46%received propofol during ECMO as part of sedation regimen. The use of propofol was not found to be associated with an increased incidence of oxygenator failure when compared with cohorts who did not receive propofol (21% propofol arm vs. 6% control, p = 0.13). When analyzed for anticoagulation omission effects, propofol did not increase the risk of oxygenator failure (p = 0.63). The only predictor that statistically predicted the risk of oxygenator failure was development of heparin-induced thrombocytopenia (HIT) during ECMO. The results of this study further support the previously reported safety of propofol utilization during respiratory ECMO even in the absence of anticoagulation.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Nutrition Support During Pediatric Extracorporeal Membrane Oxygenation

Providing adequate nutrition to critically ill pediatric patients is essential and positively impacts outcomes. Critically ill infants and children receiving extracorporeal membrane oxygenation (ECMO) therapy are nutritionally vulnerable, yet there are challenges to reliable assessment of nutrition requirements and to the delivery of optimal nutrition in this cohort. In this review of the relevant literature, we present the current evidence and guidelines for the optimal prescription and delivery of nutrition for pediatric patients receiving ECMO. We also discuss nutrient delivery considerations in ECMO survivors and identify areas where further study is needed.

Pharmacological and mechanical management of calcium channel blocker toxicity

Cardiovascular instability associated with calcium channel blocker toxicity comprises a small percentage of overdose presentations, yet they are associated with a high mortality rate. We detail the management of a 64-year-old man who took an intentional overdose of 840 mg nimodipine. We include the treatment he received and highlight the scarcity of evidence behind the use of gastric decontamination, calcium, glucagon, intravenous lipid emulsion, high-dose insulin therapy, sodium bicarbonate, vasopressors and methylene blue in calcium channel blocker toxicity. Additionally, the article explores the use of electrical pacing and venoarterial extracorporeal membrane oxygenation (VA-ECMO). Following successful weaning of VA-ECMO, the patient was successfully extubated but remained neurologically impaired due to hypoxic-ischaemic brain injury, critical care polyneuropathy and renal failure requiring dialysis. He has cerebral performance category 3; he has mild cognitive impairment but able to perform some activities of daily living independently and communicate his thoughts and needs. He requires no respiratory or cardiovascular support.

Neonatal Extracorporeal Life Support: A Review of Nutrition Considerations

Critically ill neonates who require extracorporeal life support have particular nutrition needs. These infants require prescription of aggressive, early nutrition support by knowledge providers. Understanding the unique metabolic demands and nutrition requirements of these fragile patients is paramount, particularly if additional therapies such as aggressive diuretic regimens or continuous renal replacement therapy are used concurrently. Although the American Society for Parenteral and Enteral Nutrition has published guidelines for this population, a review of each nutrition component is warranted because few studies exist specific to this population. Long-term complications in survivors of neonatal extracorporeal life support, particularly in patients with select diagnoses such as congenital diaphragmatic hernia, can be significant and must be recognized and anticipated. This review focuses on recognizing the nutrition needs of neonatal patients requiring extracorporeal life support, appraising the available data to guide selection of an appropriate mode of nutrition delivery, and describing the anticipated long-term nutrition implications of extracorporeal life support provision during the neonatal period.

Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration

BACKGROUND

Intravenous lipid emulsions (ILEs) were initially developed to provide parenteral nutrition. In recent years, ILE has emerged as a treatment for poisoning by local anesthetics and various other drugs. The dosing regimen for the clinical toxicology indications differs significantly from those used for parenteral nutrition. The evidence on the efficacy of ILE to reverse acute toxicity of diverse substances consists mainly of case reports and animal experiments. Adverse events to ILE are important to consider when clinicians need to make a risk/benefit analysis for this therapy.

METHODS

Multiple publication databases were searched to identify reports of adverse effects associated with acute ILE administration for either treatment of acute poisoning or parenteral nutrition. Articles were selected based on pre-defined criteria to reflect acute use of ILE. Experimental studies and reports of adverse effects as a complication of long-term therapy exceeding 14 days were excluded.

RESULTS

The search identified 789 full-text articles, of which 114 met the study criteria. 27 were animal studies, and 87 were human studies. The adverse effects associated with acute ILE administration included acute kidney injury, cardiac arrest, ventilation perfusion mismatch, acute lung injury, venous thromboembolism, hypersensitivity, fat embolism, fat overload syndrome, pancreatitis, extracorporeal circulation machine circuit obstruction, allergic reaction, and increased susceptibility to infection.

CONCLUSION

The emerging use of ILE administration in clinical toxicology warrants careful attention to its potential adverse effects. The dosing regimen and context of administration leading to the adverse events documented in this review are not generalizable to all clinical toxicology scenarios. Adverse effects seem to be proportional to the rate of infusion as well as total dose received. Further safety studies in humans and reporting of adverse events associated with ILE administration at the doses advocated in current clinical toxicology literature are needed.

Venoarterial extracorporeal membrane oxygenation for the management of massive amlodipine overdose

A 50-year-old man was admitted to the intensive care unit with respiratory failure and shock after suffering a massive overdose of amlodipine, lisinopril and hydrochlorothiazide. Despite mechanical ventilation, vasopressors, calcium gluconate, hyperinsulinemia-euglycemia therapy, methylene blue and intravenous fat emulsion, the patient's respiratory and hemodynamic status deteriorated. Venoarterial extracorporeal membrane oxygenation (ECMO) was initiated to provide cardiopulmonary support in the setting of profound respiratory failure and refractory shock. The patient was placed on ECMO 19 hours after arrival to the hospital, after which vasopressor and ventilatory requirements decreased significantly. The patient was decannulated from ECMO after 8 days and was discharged home after a 56-day hospitalization. Early institution of ECMO should be considered for the management of respiratory failure and refractory shock in the setting of calcium channel blocker overdose when medical therapies are insufficient.

Nutrition Implications of Heart Failure and Heart Transplantation in Children With Dilated Cardiomyopathy

This article describes nutrition implications of pediatric dilated cardiomyopathy leading to heart transplantation with a focus on nutritional management of patients during the waiting time for a donor organ and the inpatient postoperative period. Optimization of nutritional status is essential during these periods as weight loss and malnutrition contribute to muscle atrophy, decreased functional capacity, reduced immune function, and prolonged hospital stay. Nutrition implications of heart failure vary with patient’s age and degree of symptoms. Infants may have increased caloric needs and poor feeding often due to tachypnea. Older children, 1-18 years, may have decreased appetite, abdominal pain, and vomiting. Ventricular assist devices or extracorporeal membrane oxygenation, necessary to sustain life in some cases, have additional nutrition implications related to wound healing from insertion of the device and device-related complications that can include pancreatitis and the need for total parenteral nutrition. Once symptomatic heart failure is relieved and heart transplant occurs, caloric needs often decrease while interest in eating can increase profoundly, changing the overall nutrition diagnosis and the need for nutrition support. A case series involving an infant, a young child, and an adolescent is presented to illustrate nutritional challenges and interventions for pediatric patients awaiting heart transplant and the inpatient postoperative period.