Effect of Supplemental Parenteral Nutrition Versus Enteral Nutrition Alone on Clinical Outcomes in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The Efficacy of Machine Learning Models for Predicting the Prognosis of Heart Failure: A Systematic Review and Meta-Analysis

INTRODUCTION

Heart failure (HF) is a major global public health concern. The application of machine learning (ML) to identify individuals at high risk and enable early intervention is a promising approach for improving HF prognosis. We aim to systematically evaluate the performance and value of ML models for predicting HF prognosis.

METHODS

PubMed, Web of Science, Scopus, and Embase online databases were searched up to April 30, 2023, to identify studies on the use of ML models to predict HF prognosis. HF prognosis primarily encompasses readmission and mortality. The meta-analysis was conducted by MedCalc software. Subgroup analyses include grouping based on types of ML models, time intervals, sample sizes, the number of predictive variables, validation methods, whether to conduct hyperparameter optimization and calibration, data set partitioning methods.

RESULTS

A total of 31 studies were included. The most common ML models were random forest, boosting, support vector machine, neural network. The area under the receiver operating characteristic curve (AUC) for predicting HF readmission was 0.675 (95% CI: 0.651-0.699, p < 0.001), and the AUC for predicting HF mortality was 0.790 (95% CI: 0.765-0.816, p < 0.001). Subgroup analyses revealed that models with the prediction time interval of 1 year, sample sizes ≥10,000, the number of predictive variables ≥100, external validation, hyperparameter tuning, calibration adjustment, and data set partitioning using 10-fold cross-validation exhibited favorable performance within their respective subgroups.

CONCLUSION

The performance of ML models in predicting HF readmission is relatively poor, while its performance in predicting HF mortality is moderate. The quality of the relevant studies is generally low, it is essential to enhance the predictive capabilities of ML models through targeted improvements in practical applications.

Parenteral Nutrition in the Critically Ill Adult: A Narrative Review

Malnutrition in adult intensive care unit patients is associated with poor clinical outcomes. Providing adequate nutritional support to the critically ill adult should be an important goal for the intensivist. This narrative review aims to delineate the role of parenteral nutrition (PN) in meeting nutritional goals. We examined the data regarding the safety and efficacy of PN compared to enteral nutrition. In addition, we describe practical considerations for the use of PN in the ICU including patient nutritional risk stratification, nutrient composition selection for PN, route of PN administration, and biochemical monitoring.

Nutritional care in patients undergoing laparoscopic/minimally invasive surgeries for gastrointestinal tumours

The introduction of minimally invasive surgeries for gastrointestinal tumours has been associated with many favourable postoperative outcomes and a reduced impact on nutritional status. The literature review begins by discussing the impact of minimally invasive procedures on the nutritional status of patients with gastrointestinal tumours, followed by indications for enteral nutrition (EN) in this population, including preoperative nutritional support and postoperative nutritional support. The review then examines the evidence that favours the use of EN in this population, including studies demonstrating improved outcomes with preoperative EN and reduced postoperative complications with postoperative EN. It also discusses potential strategies for improving outcomes with EN, such as early initiation of feeding and individualized nutrition plans. Overall, current evidence shows that EN improves outcomes, reduces complications, and enhances the quality of life. However, the optimal timing, composition of EN, and long-term outcomes are still unclear, indicating the need for future investigations.

Implementation of the ESPEN guideline on clinical nutrition in the intensive care unit (ICU): It is time to move forward!: A position paper from the 'nutrition in the ICU' ESPEN special interest group

Nutritional assessment and provision of nutritional therapy are a core part of intensive care unit (ICU) patient treatment. The ESPEN guideline on clinical nutrition in the ICU was published in 2019. However, uncertainty and difficulties remain regarding its full implementation in daily practice. This position paper is intended to help ICU healthcare professionals facilitate the implementation of ESPEN nutrition guidelines to ensure the best care for their patients. We have aimed to emphasize the guideline recommendations that need to be implemented in the ICU, are advised, or are optional, and to give practical directives to improve the guideline recommendations in daily practice. These statements were written by the members of the ICU nutrition ESPEN special interest group (SIG), based on a survey aimed at identifying current practices relating to key issues in ICU nutrition. The ultimate goal is to improve the ICU patients quality of care.

Effect of early achievement of energy target by different nutritional support strategies on nosocomial infections in patients undergoing major abdominal surgery: a secondary analysis of two randomized clinical trials

BACKGROUND

The effect of early achievement of energy targets (EAETs) using different nutritional support strategies in patients undergoing major abdominal surgery is unclear. This study determined the impact of EAETs on the incidence of nosocomial infections in patients undergoing major abdominal surgery.

METHODS

This was a secondary analysis of two open-label randomized clinical trials. Patients from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and at nutritional risk (Nutritional risk screening 2002≥3) were divided into two groups based on whether they met the 70% energy targets, the EAET (521 EAET and non-achievement of energy target (114 NAET) groups. The primary outcome was the incidence of nosocomial infections between postoperative day 3 and discharge, and the secondary outcomes were actual energy and protein intake, postoperative noninfectious complications, intensive care unit admission, mechanical ventilation, and hospital stay.

RESULTS

Overall, 635 patients [mean (SD) age, 59.5 (11.3) years] were included. The EAET group received more mean energy between days 3 and 7 than the NAET group (22.7±5.0 vs. 15.1±4.8 kcal/kg/d; P <0.001). The EAET group had significantly fewer nosocomial infections than the NAET group [46/521(8.8%) vs. 21/114(18.4%); risk difference, 9.6%; 95% CI, 2.1-17.1%; P =0.004]. A significant difference was found in the mean (SD) number of noninfectious complications between the EAET and NAET groups [121/521(23.2%) vs. 38/114(33.3%); risk difference, 10.1%; 95% CI, 0.7-19.5%; P =0.024]. The nutritional status of the EAET group was significantly improved at discharge compared with the NAET group ( P <0.001), and other indicators were comparable between groups.

CONCLUSION

EAETs was associated with fewer nosocomial infections and improved clinical outcomes, regardless of the nutritional support strategy (early enteral nutrition alone or combined with early supplemental parenteral nutrition).

Personalized nutrition therapy in critical care: 10 expert recommendations

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes

Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.

Impact of Intensive Care Unit Nutrition on the Microbiome and Patient Outcomes

The bipartite relationship between nutrition and the intestinal microbiome represents an exciting frontier in critical care medicine. In this review, the authors first address these topics independently, leading with a summary of recent clinical studies assessing intensive care unit nutritional strategies, followed by an exploration of the microbiome in the context of perioperative and intensive care, including recent clinical data implicating microbial dysbiosis as a key driver of clinical outcomes. Finally, the authors address the intersection of nutrition and the microbiome, exploring the use of supplemental pre-, pro-, and synbiotics to influence microbial composition and improve outcomes in critically ill and postsurgical patients.

Impact of Nutritional Management on Survival of Critically Ill Malnourished Patients with Refeeding Hypophosphatemia

BACKGROUND

Early nutritional therapy may aggravate hypophosphatemia in critically ill patients.

AIM

To investigate the influence of the type nutritional therapy on the survival of critically-ill malnourished patients at refeeding hypophosphatemia risk.

METHODS

Retrospective cohort study including malnourished, critically-ill adults, admitted from June 2014-December 2017 in an intensive care unit (ICU) at a tertiary hospital. Refeeding hypophosphatemia risk was defined as low serum phosphorus levels (<2.5 mg/dL) seen at two timepoints: before the initiation and at day 4 of the nutritional therapy. Patients receiving enteral nutrition (EN) were compared with those receiving supplemental parenteral nutrition (SPN-EN plus parenteral nutrition). Primary outcome was 60 d survival. Secondary endpoint was the incidence of refeeding hypophosphatemia risk.

RESULTS

We included 468-321 patients (68.6%) received EN and 147 (31.4%) received SPN. The mortality rate was 36.3% (n = 170). Refeeding hypophosphatemia risk was found in 116 (24.8%) patients before and in 177 (37.8%) at day 4 of nutritional therapy. The 60 d mean survival probability was greater for patients receiving SPN both before (42.4 vs. 22.4%, p = 0.005) and at day 4 (37.4 vs. 25.8%, p = 0.014) vs. patients receiving EN at the same timepoints. Cox regression showed a hazard ratio of 3.3 and 2.4 for patients at refeeding hypophosphatemia risk before and at day 4 of EN, respectively, compared to the SPN group at the same timepoints.

CONCLUSION

Refeeding hypophosphatemia risk was frequent in malnourished ICU patients and the survival for patients receiving SPN seemed associated with better survival than EN only.

High-fat low-carbohydrate enteral feeding enriched with olive oil and acute respiratory failure: A double-blind, randomized, controlled trial

BACKGROUND AND AIM

The study evaluated the impact of two types of high fat diet on the outcomes of acute pulmonary failure.

METHODS

A total of 93 Ventilated acute pulmonary failure patients with enteral feeding were assigned randomly to the control group with carbohydrate-based formula (protein: 20%, fat: 30%, carbohydrate: 50%) and two study groups with fat-based formula, including group A (protein: 20%, In equal proportions of olive and sunflower oil 45%, charbohydrate:35%) and group B (protein: 20%, sunflower oil:45%, charbohydrate:35%). The diets were prescribed for 14 days.

RESULTS

In each group, 16 patients completed the study. The PaCO2 decreased significantly in the study group A compared with the control group at weaning. The risk of separation from mechanical ventilation during study period was eight times higher in the study group A than the control group. On day 10 of intervention, serum hs-CRP decreased significantly in the control group and the study group A compared to the baseline. Serum concentration of total antioxidant capacity was increased significantly in the study group A on day 10 of the intervention, but in the other two groups it was reduced. Gastrointestinal complications, including diarrhea and high gastric residual volume, were not different between the groups.

CONCLUSION

With a fat-based diet high in olive oil, more patients were weaned during the study period. This diet reduced the PaCo₂ at weaning, reduced the serum level of hs-CRP, and increased the serum level of total antioxidant capacity concentration. Fat-based diet high in sunflower oil did not have any beneficial effects on outcomes.

Clinical nutrition issues in 2022: What is missing to trust supplemental parenteral nutrition (SPN) in ICU patients?

A multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.

Acute Pancreatitis: Diagnosis and Treatment

Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.

Effect of supplemental parenteral nutrition on all-cause mortality in critically Ill adults: A meta-analysis and subgroup analysis

Objective

Several observational studies have demonstrated that increased nutritional delivery by supplemental parenteral nutrition (SPN) plus enteral nutrition (EN) reduces the rate of all-cause mortality in critically ill patients. Therefore, we aimed to compare and evaluate the effect of SPN plus EN on all-cause mortality in critically ill adults.

Methods

Randomized controlled trials were retrieved from PubMed, Embase, Google Scholar, Cochrane Library, and Sinomed (up to May 2021). Adults with severe illness treated with SPN plus EN or with EN alone were enrolled. The risk of bias was evaluated using the Newcastle-Ottawa scale, and a meta-analysis was conducted using Stata software. The primary outcome was all-cause mortality and was evaluated by pooled odds ratio (OR) with the fixed-effects model. Required information size was also calculated using trial sequential analysis.

Results

We identified 10 randomized controlled trials, with a total of 6,908 patients. No significant differences in rate of all-cause mortality (OR = 0.96, 95% CI: 0.84-1.09, P = 0.518), intensive care unit (ICU) mortality (OR = 0.90, 95% CI: 0.75-1.07, P = 0.229), and hospital mortality (OR = 0.95, 95% CI: 0.82-1.10, P = 0.482) were found between the SPN plus EN and EN alone groups. SPN plus EN support was associated with a significantly decreased risk of infection (OR = 0.83, 95% CI: 0.74-0.93, P = 0.001), although the duration of mechanical ventilation [standardized mean difference (SMD) = - 0.20], length of hospital stay (SMD = 0.12), and ICU stay (SMD = - 0.57) were similar between the two groups (all P > 0.05). Meta-regression analyses showed no significant correlations between all-cause mortality and baseline clinical factors, including patients' age, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, time of SPN initiation, and follow-up duration (all P > 0.05). Subgroup analysis showed that SPN plus EN support was associated with a trend toward decreased rate of all-cause mortality in studies with follow-up < 30 days (OR = 0.61, 95% CI: 0.36-1.02, P = 0.058). Trial sequence analysis showed that the required information size for all-cause mortality was 16,972, and the cumulative Z-curve indicated no significant differences in the risk of all-cause mortality between the two groups (P > 0.05).

Conclusion

SPN plus EN support can significantly reduce the risk of infection, although it has no significant effect on all-cause mortality among critically ill patients. More studies are warranted to confirm these findings.

Effect of accelerated rehabilitation combined with enteral nutrition on gastrointestinal function recovery after hepatectomy

OBJECTIVE

To investigate the effect of accelerated rehabilitation combined with enteral nutrition on the recovery of gastrointestinal function in patients after hepatectomy.

METHODS

In this prospective randomized controlled study, a total of 108 patients with liver cancer who underwent hepatectomy in our hospital from November 2020 to December 2021 were selected as the research subjects. According to the random number table method, the patients were divided into a research group (54 cases, who received accelerated rehabilitation combined with enteral nutrition) and a control group (54 cases, who received routine nursing without enteral nutrition). The gastrointestinal function of patients in two groups was recorded and compared, the nutritional status before and after surgery was compared, and the levels of T cell subsets CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺, and liver function were compared between the two groups. The adverse reactions such as catheter infection, diarrhea, vomiting, intestinal obstruction, and ascites occurred in two groups were recorded.

RESULTS

The gastrointestinal function of patients in research group was significantly better than that in control group (P < 0.05). After intervention, the albumin (ALB) in research group was significantly higher than that in control group (P < 0.05), but no significant difference in body weight between two groups was found (P > 0.05). After intervention, CD3⁺, CD4⁺, CD8⁺, and CD4⁺/CD8⁺ in the research group were significantly higher than those in the control group (P < 0.05). In addition, there was no significant difference in liver function indexes between the two groups (P > 0.05); however, the incidence of adverse reactions in research group was significantly lower than that in the control group (P < 0.05).

CONCLUSION

Accelerated rehabilitation combined with enteral nutrition can effectively restore the gastrointestinal function of patients after hepatectomy, which is worthy of clinical promotion.

Characteristics of patients receiving nutrition care and its associations with prognosis in a tertiary hospital

OBJECTIVE

The aim of this study was to describe the medical nutritional therapy (MNT) of adult non-critically ill hospitalization patients.

METHODS

In a retrospective study, adults hospitalized for more than 48 h in non-intensive care unit medical and surgical areas that were classified as being at nutritional risk were included. Malnutrition was defined according to Global Leadership Initiative on Malnutrition (GLIM) criteria.

RESULTS

A total of 255 patients, aged 54.13±18.4 years, who were at risk of malnutrition were included in this study. Of these, 50% were males. Notably, 52.5% received oral nutrition supplementation (ONS), 23.5% enteral nutrition (EN), 15% parenteral nutrition (PN), and 9% received enteral and parenteral nutrition (EPN). Patients with EPN presented the highest frequency of malnutrition (52%), and therefore they received more than 100% of energy and protein requirements. The median length of stay was 25 days. Among patients with nutritional risk receiving EPN, no deaths occurred. Patients, identified at nutritional risk, but without malnutrition according to GLIM, and receiving ONS had significantly lower mortality than patients receiving other MNT.

CONCLUSIONS

Oral nutrition supplementation was the more frequent MNT prescribed. The frequency of malnutrition and percentage of prescribed energy and protein were higher in patients receiving PN and EPN compared with those receiving ONS.

Gastrointestinal dysfunction during enteral nutrition delivery in intensive care unit (ICU) patients: Risk factors, natural history, and clinical implications. A post-hoc analysis of The Augmented versus Routine approach to Giving Energy Trial (TARGET)

BACKGROUND

Slow gastric emptying occurs frequently during critical illness and is roughly quantified at bedside by large gastric residual volumes (GRVs). A previously published trial (The Augmented versus Routine approach to Giving Energy Trial; TARGET) reported larger GRVs with energy-dense (1.5 kcal/mL) compared with standard (1.0 kcal/mL) enteral nutrition (EN), warranting further exploration.

OBJECTIVE

To assess the incidence, risk factors, duration, and timing of large GRVs (≥250 mL) and its relation to clinical outcomes in mechanically ventilated adults.

METHODS

A post-hoc analysis of TARGET data in patients with ≥1 GRV recorded. Data are n (%) or median [IQR].

RESULTS

Of 3876 included patients, 1777 (46%) had ≥1 GRV ≥250 mL, which was more common in males (50 compared with 39%; P < 0.001) and in patients receiving energy-dense compared with standard EN (52 compared with 40%; RR = 1.27 (95% CI: 1.19, 1.36); P < 0.001) in whom it also lasted longer (1 [0-2] compared with 0 [0-1] d; P < 0.001), with no difference in time of onset after EN initiation (day 1 [0-2] compared with 1 [0-2]; P = 0.970). Patients with GRV ≥250 mL were more likely to have the following: vasopressor administration (88 compared with 76%; RR = 1.15 [1.12, 1.19]; P < 0.001), positive blood cultures (16 compared with 8%; RR = 1.92 [1.60, 2.31]; P < 0.001), intravenous antimicrobials (88 compared with 81%; RR = 1.09 [1.06, 1.12]; P < 0.001), and prolonged intensive care unit (ICU) stay (ICU-free days to day 28; 12.9 [0.0-21.0] compared with 20.0 [3.9-24.0]; P < 0.001), hospital stay (hospital-free days to day 28: 0.0 [0.0-12.0] compared with 7.0 [0.0-17.6] d; P < 0.001), ventilatory support (ventilator-free days to day 28: 16.0 [0.0-23.0] compared with 22.0 [8.0-25.0]; P < 0.001), and a higher 90-d mortality (29 compared with 23%; adjusted: RR = 1.17 [1.05, 1.30]; P = 0.003).

CONCLUSION

Large GRVs were more common in males and those receiving energy-dense formulae, occurred early and were short-lived, and were associated with a number of negative clinical sequelae, including increased mortality, even when adjusted for illness severity. This trial was registered at clinicaltrials.gov as NCT02306746.

Early supplemental parenteral nutrition for the achievement of nutritional goals in subarachnoid hemorrhage patients: An observational cohort study

Purpose

Enteral nutrition (EN) often fails to achieve nutritional goals in neurocritical care patients. We sought to investigate the safety and utility of supplemental parenteral nutrition (PN) in subarachnoid hemorrhage (SAH) patients.

Materials and methods

Data of 70 consecutive patients with non-traumatic SAH admitted to the neurological intensive care unit of a tertiary referral center were prospectively collected and retrospectively analyzed. We targeted the provision of 20–25 kilocalories per kilogram bodyweight per day (kcal/kg/d) by enteral nutrition. Supplemental PN was given when this target could not be reached. Nutritional data were analyzed for up to 14 days of ICU stay. Hospital complications were tested for associations with impaired enteral feeding. The amounts of EN and PN were tested for associations with the level of protein delivery and functional outcome. Repeated measurements within subjects were handled utilizing generalized estimating equations.

Results

Forty (27 women and 13 men) of 70 screened patients were eligible for the analysis. Median age was 61 (IQR 49–71) years, 8 patients (20%) died in the hospital. Thirty-six patients (90%) received PN for a median duration of 8 (IQR 4–12) days. The provision of 20 kcal/kg by EN on at least 1 day of ICU stay was only achieved in 24 patients (60%). Hydrocephalus (p = 0.020), pneumonia (p = 0.037) and sepsis (p = 0.013) were associated with impaired enteral feeding. Neither the amount nor the duration of PN administration was associated with an increased risk of severe complications or poor outcome. Supplemental PN was associated with significantly increased protein delivery (p<0.001). In patients with sepsis or pneumonia, there was an association between higher protein delivery and good functional outcome (p<0.001 and p = 0.031), but not in the overall cohort (p = 0.08).

Conclusions

Enteral feeding was insufficient to achieve nutritional goals in subarachnoid hemorrhage patients. Supplemental PN was safe and associated with increased protein delivery. A higher protein supply was associated with good functional outcome in patients who developed sepsis or pneumonia.

Nutrition support for critically ill patients

Nutrition support is an important aspect of the management of critically ill patients. This review highlights the emerging evidence on critical care nutrition and focuses on the pathophysiologic interplay between critical illness, the gastrointestinal tract, and nutrition support and the evidence on the best route, dose, and timing of nutrition. Although indirect calorimetry is recommended to measure energy expenditure, predictive equations are commonly used but are limited by their inaccuracy in individual patients. The current evidence supports early enteral nutrition (EN) in most patients, with a gradual increase in the daily dose over the first week. Delayed EN is warranted in patients with severe shock. According to recent trials, parenteral nutrition seems to be as effective as EN and may be started if adequate EN is not achieved by the first week of critical illness. A high protein dose has been recommended, but the best timing is unclear. Immuno-nutrition should not be routinely provided to critically ill patients. Patients receiving artificial nutrition should be monitored for metabolic derangements. Additional adequately powered studies are still needed to resolve many unanswered questions.

The Role of Dysbiosis in Critically Ill Patients With COVID-19 and Acute Respiratory Distress Syndrome

In late December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) quickly spread worldwide, and the syndrome it causes, coronavirus disease 2019 (COVID-19), has reached pandemic proportions. Around 30% of patients with COVID-19 experience severe respiratory distress and are admitted to the intensive care unit for comprehensive critical care. Patients with COVID-19 often present an enhanced immune response with a hyperinflammatory state characterized by a "cytokine storm," which may reflect changes in the microbiota composition. Moreover, the evolution to acute respiratory distress syndrome (ARDS) may increase the severity of COVID-19 and related dysbiosis. During critical illness, the multitude of therapies administered, including antibiotics, sedatives, analgesics, body position, invasive mechanical ventilation, and nutritional support, may enhance the inflammatory response and alter the balance of patients' microbiota. This status of dysbiosis may lead to hyper vulnerability in patients and an inappropriate response to critical circumstances. In this context, the aim of our narrative review is to provide an overview of possible interaction between patients' microbiota dysbiosis and clinical status of severe COVID-19 with ARDS, taking into consideration the characteristic hyperinflammatory state of this condition, respiratory distress, and provide an overview on possible nutritional strategies for critically ill patients with COVID-19-ARDS.

The effect of short term peripheral parenteral nutrition on treatment outcomes and mortality in critically ill pediatric canine patients

Background

Peripheral parenteral nutrition (PPN) is increasingly considered as an alternative to central parenteral nutrition (CPN) given the higher cost and more frequent clinical complications associated with the latter. However, the assessment of potential risks and benefits of PPN in critically ill pediatric canine patients has not been extensively performed. In this study, we aimed to explore the effect of short-term, hypocaloric PPN on weight loss, length of hospital stay, the incidence of complications, adverse effects, and mortality in critically ill pediatric canine patients.

Results

Between August 2015 and August 2018, a total of 59 critically ill pediatric canine patients aged from 1 to 6 months admitted at the Veterinary Sciences Research Institute of the Autonomous University of Baja California were included in this non-randomized clinical trial. Canine pediatric patients were initially allocated to 3 groups: 11 in group 1 receiving parenteral nutrition (PN) supplementation equivalent to 40% of the resting energy requirement (RER), 12 in group 2 receiving supplementation of 50% of the RER, and 36 in group 3 receiving no PN supplementation. After establishing that there was no significant difference between 40 and 50% of PN supplementation, these groups were not separated for downstream analysis.

Similar lengths of hospital stays were noted among study subjects who received PN supplementation and those who did not (4.3 ± 1.5 vs. 5.0 ± 1.5, days, p = 0.097). No metabolic-, sepsis- or phlebitis-related complications were observed in any animal in the PPN supplemented group. Higher mortality (19.4% vs. 0%, p = 0.036), and a greater percentage of weight loss (9.24% vs. 0%, p <  0.001) were observed in patients who received no supplementation.

Conclusion

Even though short-term, hypocaloric PPN did not reduce the length of hospital stay, it was associated with lower mortality and resulted in mitigation of weight loss. In contrast to previous studies evaluating central and peripheral parenteral nutrition protocols, we observed a lower frequency of metabolic, septic, and phlebitis complications using a 40–50% parenteral nutrition treatment. The parenteral nutrition therapeutic intervention used in our study may reduce PN-related adverse effects and promote a favorable disease outcome in critically ill canine patients. Larger studies will be needed to confirm these observations.

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis

BACKGROUND

Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence.

METHODS

This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes.

RESULTS

Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P = .99), hospital LOS (mean difference, -1.44; CI, -5.59 to 2.71; P = .50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials.

CONCLUSION

A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.

The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis

BACKGROUND

Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery.

METHODS

The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome.

RESULTS

From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I² = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN.

CONCLUSION

EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.

[The XI SENPE Jesús Culebras Lecture. Enteral nutrition in critically ill patients. History of an evolution]

Introduction

Enteral nutrition is part of the treatment plan designed for a great number of critically ill patients. After a first description in ancient Egypt, enteral nutrition was only rapidly developed during the last century. Advances in indications, tube feeding methods, enteral formula selection, diagnosis and treatment of gastrointestinal-related complications, efficacy monitorization, and use of protocols for enteral nutrition administration in clinical practice make this nutritional technique more feasible and secure for critically ill patients. Nevertheless, several issues in this field need more investigation to increase enteral nutrition development, efficacy, and safety in these patients.

Effects of intermittent feeding versus continuous feeding on enteral nutrition tolerance in critically ill patients: A protocol for systematic review and meta-analysis

BACKGROUND

Nutritional support is an indispensable treatment for critically ill patients. Enteral nutrition intolerance is one of the obstacles to the smooth progress of enteral nutrition.Enteral nutrition can be divided into continuous feeding and intermittent feeding. However, the effectiveness and safety of the 2 ways of nutrition infusion are controversial clinically. Therefore, this meta-analysis further evaluated the effect of intermittent feeding versus continuous feeding on enteral nutrition tolerance in critically ill patients.

METHODS

Cochrane Library, PubMed, Web of Science, EMbase, China Biology Medicine disc (CBM), China Science and Technology Journal Database (VIP), China Journal full-text Database (CNKI), and Wanfang Database were searched for all randomized controlled trials (RCTs) on the effects of intermittent and continuous feeding on enteral nutrition tolerance in critically ill patients. The quality of literatures was strictly evaluated and the data were extracted by 2 investigators. Meta-analysis was carried out by applying RevMan 5.5 software.

RESULTS

The results of this meta-analysis are published in peer-reviewed journals.

CONCLUSIONS

This study provides reliable evidence-based support for the effects of intermittent and continuous feeding on enteral nutrition tolerance in critically ill patients.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4BP5X.