Impact of Propofol Sedation upon Caloric Overfeeding and Protein Inadequacy in Critically Ill Patients Receiving Nutrition Support

It is not just about prescription. A cohort study of the impact of enteral nutrition on mortality of hospitalized patients with COVID-19

Introduction

Introduction: during COVID-19 pandemic, international societies released guidelines and recommendations for patients requiring nutritional support according to previous similar respiratory diseases. Objectives: the aim of the study was to evaluate the nutritional support provided by enteral nutrition (EN) in patients with COVID-19 infection, identify if the recommendations from international societies were met and their impact on mortality rate. Methods: a cohort study was conducted on adult patients with COVID-19 admitted to a tertiary hospital. Demographic, clinical, biochemical, and nutritional variables were obtained. A random-effect parametric survival-time model was performed to quantify the risk of death for each variable, and the Hausman test was used to confirm the model. Results: two hundred and twenty-nine patients were enrolled. The delivered energy was > 80 % of adequacy in the first two days, as suggested by international guidelines (11.7 ± 4.9 kcal/kg); however, an adequacy rate less than 60 % was achieved on day 14 (25.4 ± 7.4 kcal/kg). The protein adequacy was > 75 % on the first days of infusion (1.3 ± 0.3 g/kg); however, the infusion was < 50 % (1.5 ± 0.4 g/kg) after being extubated. Age, sex, and nutritional risk were related to higher mortality in patients with EN, whereas the infused energy and protein, the percentage of protein adequacy, arginine, and n-3 PUFA were associated with lower mortality. Conclusion: achieving at least 80 % of the energy and protein requirements, as well as n-3 PUFA and arginine supplementation could be associated with lower mortality in COVID-19 patients. More studies are needed to confirm the role of these nutrients on the mortality rate.

Sedation for Patients with Sepsis: Towards a Personalised Approach

This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.

Medical nutrition therapy in patients receiving ECMO: Evidence-based guidance for clinical practice

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.

An analysis of non-nutritive calories from propofol, dextrose, and citrate among critically ill patients receiving continuous renal replacement therapy

BACKGROUND

Propofol, dextrose, and citrate infusions are necessary treatment modalities in the intensive care units (ICUs). They are, however, a potential source of non-nutritive calories (NNCs) which may cause over-feeding and adverse complications. The literature surrounding the role of NNCs is limited. We aimed to examine the energy contribution of NNCs. Our secondary aim is to assess the nutritional impact of NNCs, especially among patients receiving continuous renal replacement therapy (CRRT).

MATERIALS /METHODS

We enrolled 177 mechanically ventilated patients admitted to medical-surgical ICUs from August to December 2019. Patients were monitored over the first 7 days of admission. Infusion rates of EN/PN and NNCs, as well as clinical characteristics, were examined. Patients receiving CRRT were compared to those without.

RESULTS

In total, 24% received additional energy from citrate. Patients received a maximum of 331kcal from citrate, 492kcal from propofol, and 992kcal from dextrose per ICU day. CRRT-group achieved higher total energy on the first two days (Day 1 - 55.1% vs. 46.4%; p=0.008, Day 2 - 73.2% vs. 55.4%, p=0.025). They also received higher mean NNCs on all days, except for Day 1 (p=0.068).

CONCLUSION

NNCs, especially citrate, are significant sources of energy. Patients receiving CRRT may have greater nutritional risk. There should be close monitoring and adaption of energy prescription accordingly to prevent over-feeding. This article is protected by copyright. All rights reserved.

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines

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.