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Zhang H, Zhao L, Jia B. Research progress on nutritional support in the neonatal and pediatric populations receiving extracorporeal membrane oxygenation. Front Nutr 2024; 11:1370286. [PMID: 38887500 PMCID: PMC11180743 DOI: 10.3389/fnut.2024.1370286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024] Open
Abstract
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.
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Affiliation(s)
- Hongquan Zhang
- Zhengzhou Railway Vocational and Technical College, Zhengzhou, Henan Province, China
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Lizhuo Zhao
- Department of Pediatric ICU, Henan Provincial People’s Hospital, Zhengzhou, Henan Province, China
| | - Baohui Jia
- Department of Emergency and ICU, Fourth Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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2
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Pelekhaty S, Gessler J, Dante S, Rector N, Galvagno S, Stachnik S, Rabin J, Tabatabai A. Nutrition and outcomes in venovenous extracorporeal membrane oxygenation: An observational cohort study. Nutr Clin Pract 2024. [PMID: 38375866 DOI: 10.1002/ncp.11132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/24/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Overfeeding and underfeeding are associated with negative outcomes during critical illness. The purpose of this retrospective study was to assess the association between nutrition intake and outcomes for patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). METHODS Adults who received VV ECMO August 2017 to June 2020 were screened. Patients with <3 ECMO nutrition support days were excluded. Age, sex, height, weight, ideal body weight (IBW), body mass index, sequential organ failure assessment score, respiratory ECMO survival prediction score, energy, and protein goals were collected. All nutrition intake was collected for the first 14 days of ECMO or until death, decannulation, or oral diet initiation. Outcomes analyzed included mortality and VV ECMO duration. The relationship between nutrition delivery and outcomes was tested with multivariate analysis. Univariate analyses were conducted on obese and nonobese subgroups. RESULTS A total of 2044 nutrition days in 178 patients were analyzed. The median estimated needs were 24 (interquartile range: 22.3-28.3) kcal/kg/day and 2.25 (interquartile range: 2.25-2.77) g/kg/day of protein using IBW in patients with obesity and actual weight in patients without obesity. Patients received 83% of energy and 63.3% of protein targets. Patients with obesity who received ≥2 g/kg IBW of protein had a significantly shorter ECMO duration (P = 0.037). Increased protein intake was independently associated with a reduced risk of death (odds ratio: 0.06; 95% confidence interval: 0.01-0.43). CONCLUSION Higher protein intake was associated with reduced mortality. Optimal energy targets for patients receiving ECMO are currently unknown and warrant further study.
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Affiliation(s)
- Stacy Pelekhaty
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Julie Gessler
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Siddhartha Dante
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Samuel Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen Stachnik
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ali Tabatabai
- Department of Medicine, St Joseph's Medical Center, Towson, Maryland, USA
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3
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Hahn M, Wood A, Hasse JM. Nutrition support management of organ transplant recipients in the acute posttransplant phase. Nutr Clin Pract 2024; 39:45-58. [PMID: 38081296 DOI: 10.1002/ncp.11104] [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: 09/25/2023] [Revised: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 01/13/2024] Open
Abstract
Patients who undergo solid organ transplant can have an extensive and challenging postoperative course. The chronicity of the disease state prior to transplant in combination with transplant-specific complications and immunosuppressant medications can lead to distinct challenges that are not observed in other critically ill patients. Although the manifestation of posttransplant complications may be specific to the organ being transplanted, there are common transplant challenges that affect nutrition therapy in these patients. Effects of malnutrition, metabolic aberrations, and posttransplant organ dysfunction should be considered when developing a nutrition care plan for patients in the immediate posttransplant phase. This article addresses the various complications that can arise in the immediate posttransplant phase among patients undergoing solid organ transplant and the appropriate nutrition interventions or considerations for this specialized patient population.
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Affiliation(s)
- Michaelann Hahn
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Abby Wood
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Jeanette M Hasse
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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4
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Peng Y, Chen M, Ni H, Li S, Chen L, Lin Y. Effect of timing of enteral nutrition initiation on poor prognosis in patients after cardiopulmonary bypass: A prospective observational study. Nutrition 2023; 116:112197. [PMID: 37741090 DOI: 10.1016/j.nut.2023.112197] [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: 05/05/2023] [Revised: 07/09/2023] [Accepted: 08/13/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES Current guidelines recommend that enteral nutrition (EN) be implemented as early as possible in patients after cardiopulmonary bypass (CPB), but the optimal time to initiate EN remains controversial. Therefore, the aim of this study was to investigate the effect of timing of EN initiation on poor prognosis in patients after CPB. METHODS This was a prospective observational study with patients who underwent CPB in a tertiary hospital from September 1, 2021, to January 31, 2022. The patients were divided into three groups according to the timing of EN initiation: <24 h, 24 to 48 h, and >48 h. Unconditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals to identify independent risk factors for poor prognosis. RESULTS The study included 579 patients, of whom 255 patients had EN initiated at <24 h (44%), 226 at 24 to 48 h (39%), and at >48 h (17%). With EN <24 h as a reference, multivariate logistic analysis showed that EN 24 to 48 h (OR, 1.854, P = 0.008) and EN >48 h (OR, 7.486, P <0.001) were independent risk factors for poor prognosis after CPB. Age (OR, 1.032, P = 0.001), emergency surgery (OR, 10.051; P <0.001), surgical time (OR, 1.006; P <0.001), and sequential organ failure assessment score (OR, 1.269; P = 0.001) also increased the risk for poor prognosis after CPB. CONCLUSIONS Compared with early EN <24 h, EN 24 to 48 h and EN >48 h increased the risk for poor prognosis in patients after CPB.
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Affiliation(s)
- Yanchun Peng
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Meihua Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hong Ni
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China
| | - Sailan Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
| | - Yanjuan Lin
- Department of Nursing, Fujian Medical University Union Hospital, Fuzhou, China; Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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5
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Floro GC, Schwenger KJP, Ghorbani Y, Zidar DJ, Allard JP. In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay. Nutr Clin Pract 2023; 38:1368-1378. [PMID: 37302065 DOI: 10.1002/ncp.11019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/20/2023] [Accepted: 04/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight. METHODS This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay. RESULTS One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013). CONCLUSION In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.
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Affiliation(s)
- Geraldine C Floro
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | | | - Yasaman Ghorbani
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Deanna J Zidar
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
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6
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Dresen E, Naidoo O, Hill A, Elke G, Lindner M, Jonckheer J, De Waele E, Meybohm P, Modir R, Patel JJ, Christopher KB, Stoppe C. Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice. JPEN J Parenter Enteral Nutr 2023; 47:220-235. [PMID: 36495215 DOI: 10.1002/jpen.2467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease-associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision-making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence-based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
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Affiliation(s)
- Ellen Dresen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Omy Naidoo
- Newtricion Wellness Dieticians, PMB Healthcare Centre, Pietermaritzburg, South Africa
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Matthias Lindner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joop Jonckheer
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium
| | - Elisabeth De Waele
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Department of Clinical Nutrition, Universitair Ziekenhuis Brussel, Brussels Health Campus, Jette, Belgium.,Vrije Universiteit Brussel, Brussels Health Campus, Jette, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kenneth B Christopher
- Renal Division, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.,Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
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7
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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8
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Karpasiti T. A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:763-771. [PMID: 34324446 DOI: 10.1097/mat.0000000000001540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in patients with severe cardiorespiratory failure has seen significant growth in the last decade. Despite this, there is paucity of data surrounding the optimum nutritional management for ECMO patients. This review aimed to describe current nutrition practices in patients receiving ECMO, critically appraise available studies and identify areas for future research. A literature search was conducted in PubMed, MEDLINE, and CINAHL Plus to identify all randomized trials and observational studies published between July 2000 and July 2020 investigating nutrition practices in critically ill adults receiving ECMO. The primary outcomes were nutritional adequacy, gastrointestinal complications, and physical function. Secondary outcomes included mortality, length of stay, and duration on ECMO support. From a total of 31 studies identified, 12 met the inclusion criteria. Nine observational studies were reviewed following eligibility assessment. Early enteral nutrition was deemed safe and feasible for ECMO patients; however, meeting nutritional targets was challenging. Utilizing alternative nutrition routes is an option, although risks and benefits should be taken into consideration. Data on gastrointestinal complications and other clinical outcomes were inconsistent, and no data were identified investigating the effects of nutrition on the physical and functional recovery of ECMO patients. Nutrition therapy in ECMO patients should be provided in line with current guidelines for nutrition in critical illness until further data are available. Further prospective, randomized studies investigating optimum nutrition practices and effects on clinical and functional outcomes are urgently required.
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Affiliation(s)
- Terpsi Karpasiti
- From the Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
- Barts Health NHS Trust, St Bartholomew's Hospital, West Smithfield, London, United Kingdom
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9
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Visvalingam R, Ridley E, Barnett A, Rahman T, Fraser JF. Nutrition adequacy, gastrointestinal and hepatic function during extracorporeal membrane oxygenation in critically ill adults: a retrospective observational study. Artif Organs 2022; 46:1886-1892. [PMID: 35451130 DOI: 10.1111/aor.14269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/17/2022] [Accepted: 04/14/2022] [Indexed: 11/28/2022]
Abstract
AIMS To identify clinical and biochemical markers associated with nutrition adequacy and gastrointestinal and liver dysfunction in adults on extracorporeal membrane oxygenation (ECMO). METHODS A retrospective, observational, study was conducted at 2 centres in Australia. Adult patients who received ECMO from July 2011 to June 2015 were included. Mode of ECMO used, fluid balance, number of systemic inflammatory response syndrome (SIRS) criteria present, vasoactive-inotropic scores (VIS) and liver function tests (LFTs) were collected for the duration of ECMO until 7 days after ECMO cessation. Multiple regression models were used to determine if the collected variables were associated with nutrition adequacy. The mean LFTs during ECMO were also compared to mean LFTs post ECMO cessation. RESULTS During the first 5 days of ECMO commencement, mean nutrition adequacy was 10% higher in the veno-venous (VV) ECMO group than in the veno-arterial (VA) group (95% confidence interval [CI], 2% to 17%). For every 5,000 ml increase of fluid balance, an associated decrease in nutrition adequacy was observed (-8%, 95% CI, -15% to -2%). A doubling of bilirubin and VIS were associated with a mean reduction in nutrition adequacy of -5% (CI -8% to -2%) and -2% (CI, -3% to -1%), respectively. CONCLUSIONS In the first 5 days of ECMO commencement, higher nutrition adequacy was associated with the VV mode of ECMO and reduced nutrition adequacy with increased fluid balance, more vasopressor and inotropic support and raised bilirubin. Prospective investigation is required to confirm whether these associations have a causal relationship.
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Affiliation(s)
- R Visvalingam
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - E Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.,Nutrition Department, The Alfred Hospital, Melbourne, Australia
| | - A Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Australia
| | - T Rahman
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Gastroenterology and Hepatology, The Prince Charles Hospital, Brisbane, Australia
| | - J F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
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10
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D'Alesio M, Martucci G, Arcadipane A, Lorusso R, Amrein K. Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines. Artif Organs 2022; 46:1240-1248. [PMID: 35230717 DOI: 10.1111/aor.14215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population. METHODS A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective. RESULTS Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day. CONCLUSIONS Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.
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Affiliation(s)
- Mark D'Alesio
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gennaro Martucci
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Antonio Arcadipane
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad alta specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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11
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Pérez G, González E, Zamora L, Fernández SN, Sánchez A, Bellón JM, Santiago MJ, Solana MJ. Early Enteral Nutrition and Gastrointestinal Complications in Pediatric Patients on Extracorporeal Membrane Oxygenation. J Pediatr Gastroenterol Nutr 2022; 74:110-115. [PMID: 34636794 PMCID: PMC8673839 DOI: 10.1097/mpg.0000000000003317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/06/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess the safety of enteral nutrition (EN) in children on extracorporeal membrane oxygenation (ECMO). To describe nutritional status and the characteristics of the nutritional support in this population. METHODS A retrospective single-center analysis (2006-2016) including children <18 years on ECMO. Demographic data, nutritional status, characteristics of nutritional support, and development of gastrointestinal (GI) complications were recorded. RESULTS One hundred children, with a median age of 9.7 months (interquartile range [IQR] 3.9-63.1) were enrolled. Undernutrition was prevalent among children on ECMO (33.3%) mainly in patients <2 years (P = 0.042). Most patients (64%) received EN at some point during ECMO therapy. EN was administered in the first 48 hours after ECMO initiation (48HEN) to 60.3% of the children.Mortality rate in the Pediatric Intensive Care Unit was lower in patients who received EN as the initial artificial nutrition support (ANS) (37.7 vs 51%, P = 0.005) and in children on 48HEN (34% vs 50%, P = 0.04). In the logistic regression analysis, duration of ECMO support and low cardiac output indication were the only factors associated with mortality.Although most patients on ECMO (45%) developed digestive complications, they were mostly mild, being constipation the most prevalent. In the logistic regression analysis, EN was not associated with an increase in GI complications (P = 0.09). Only three patients developed intestinal ischemia (one without EN and two on EN). CONCLUSIONS Undernutrition is prevalent among children on ECMO, mainly in infants <2 years. EN is not associated with severe gastrointestinal complications or higher mortality in these children.
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Affiliation(s)
- Gema Pérez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Gregorio Marañón Health Research Institute (IISGM)
| | - Elena González
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Laura Zamora
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
| | - Sarah N. Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Amelia Sánchez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | | | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón
- Maternal and Child Public Health Department. Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IISGM)
- Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
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Al-Dorzi HM, Arabi YM. Enteral Nutrition Safety With Advanced Treatments: Extracorporeal Membrane Oxygenation, Prone Positioning, and Infusion of Neuromuscular Blockers. Nutr Clin Pract 2020; 36:88-97. [PMID: 33373481 DOI: 10.1002/ncp.10621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022] Open
Abstract
This review aims at assessing the safety and efficacy of enteral nutrition in critically ill patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers. Existing data from randomized controlled trials demonstrate the survival benefit of early enteral nutrition in critically ill patients. Observational data have demonstrated that enteral nutrition in patients receiving extracorporeal membrane oxygenation, prone positioning, and infusion of neuromuscular blockers is generally safe. However, these patients are at increased risk for gastrointestinal complications from enteral nutrition because of critical illness-induced gastrointestinal dysfunction; associated shock; the concomitant use of vasopressor agents, sedatives, and narcotics; possibly mesenteric circulatory compromise; and regurgitation associated with prone positioning. Therefore, early enteral nutrition is generally recommended in these patients in the absence of severe gastrointestinal dysfunction or shock. To reduce the complications, early nutrition should be advanced gradually (trophic feeding or permissive underfeeding), the bed should be tilted to a maximum of 30°, and concentrated nutritional formulae and the use of prokinetics may be considered to treat enteral feeding intolerance. Physicians should be vigilant about monitoring for early signs of acute mesenteric ischemia, which should lead to holding enteral feeding. Parenteral nutrition may be utilized in patients who cannot receive enteral nutrition or are unable to reach their nutrition goals by the end of the first week.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Davis RC, Durham LA, Kiraly L, Patel JJ. Safety, Tolerability, and Outcomes of Enteral Nutrition in Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2020; 36:98-104. [PMID: 33078433 DOI: 10.1002/ncp.10591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/31/2020] [Accepted: 09/20/2020] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a supportive care system for patients with respiratory or cardiac failure. Patients requiring ECMO are at risk for significant inflammation, prolonged hospitalization, and acquired malnutrition and sarcopenia. Societal guidelines recommend early enteral nutrition in critically ill patients; however, in this population, optimal timing and dose of nutrition remains unknown and fear of reduced splanchnic perfusion, delayed gastric emptying, and bowel ischemia poses a barrier to appropriate energy and protein intake. This narrative review intends to provide an overview of ECMO, highlight the rationale for nutrition support in this population, and review the safety, tolerability, and outcomes associated with enteral nutrition during ECMO.
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Affiliation(s)
- Robert C Davis
- Clinical Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laszlo Kiraly
- Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Bear DE, Smith E, Barrett NA. Nutrition Support in Adult Patients Receiving Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2018; 33:738-746. [DOI: 10.1002/ncp.10211] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Danielle E. Bear
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
| | - Elizabeth Smith
- Department of Nutrition and Dietetics; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
| | - Nicholas A. Barrett
- Department of Critical Care; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Lane Fox Research Clinical Respiratory Physiology Research Centre; Guy's and St Thomas’ NHS Foundation Trust; London United Kingdom
- Centre for Human and Applied Physiological Sciences; King's College London; London United Kingdom
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