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Sankararaman S, Venegas C, Seth S, Palchaudhuri S. "Feed a Cold, Starve a Fever?" A Review of Nutritional Strategies in the Setting of Bacterial Versus Viral Infections. Curr Nutr Rep 2024; 13:314-322. [PMID: 38587572 DOI: 10.1007/s13668-024-00536-w] [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] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE OF REVIEW Some data, mostly originally derived from animal studies, suggest that low glucose intake is protective in bacterial sepsis but detrimental in overwhelming viral infections. This has been interpreted into a broad belief that different forms of sepsis may potentially require different nutritional management strategies. There are a few mechanistic differences between the host interactions with virus and bacteria which can explain why there may be opposing responses to macronutrient and micronutrient during the infected state. Here, we aim to review relevant evidence on the mechanisms and pathophysiology of nutritional management strategies in various infectious syndromes and summarize their clinical implications. RECENT FINDINGS Newer literature - in the context of the SARS-CoV-19 pandemic - offers some insight to viral infections. There is still limited clinically applicable data during infection that clearly delineate the role of nutrition during an active viral vs bacterial infections. Based on contrasting findings in different models of viruses and bacteria, the macronutrient and micronutrient needs may depend more on specific infectious organisms that may not be generalizable as bacterial versus viral. Overall, the metabolic effects of sepsis are context dependent, and various host-specific (e.g., age, baseline nutritional status, immune status, comorbidities) and illness variables (phase, duration, and severity of illness) play a significant role in determining the outcome besides pathogen-specific (virus or bacterial or fungi and combined infections) factors. Microbe therapy (probiotics and prebiotics) seems to have therapeutic potential in both viral and bacterial infected states, and this seems like a promising area for further practical research.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Carla Venegas
- Department Critical Care Medicine and Nutrition Support Team, Mayo Clinic, Jacksonville, FL, USA
| | - Sonia Seth
- Upstate Medical University, Syracuse, NY, USA
| | - Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Chen S, Chang Z. Haste makes waste: Early nutrition prescription for critically ill patients. Aging Med (Milton) 2024; 7:279-282. [PMID: 38975307 PMCID: PMC11222734 DOI: 10.1002/agm2.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/28/2024] [Accepted: 05/29/2024] [Indexed: 07/09/2024] Open
Affiliation(s)
- Siying Chen
- Department of Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
- Graduate School of Peking Union Medical CollegeBeijingChina
| | - Zhigang Chang
- Department of Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
- Graduate School of Peking Union Medical CollegeBeijingChina
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Lew CCH, Lee ZY, Day AG, Jiang X, Bear D, Jensen GL, Ng PY, Tweel L, Parillo A, Heyland DK, Compher C. The Association Between Malnutrition and High Protein Treatment on Outcomes in Critically Ill Patients: A Post Hoc Analysis of the EFFORT Protein Randomized Trial. Chest 2024; 165:1380-1391. [PMID: 38354904 DOI: 10.1016/j.chest.2024.02.008] [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: 12/12/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Preexisting malnutrition in critically ill patients is associated with adverse clinical outcomes. Malnutrition can be diagnosed with the Global Leadership Initiative on Malnutrition using parameters such as weight loss, muscle wasting, and BMI. International critical care nutrition guidelines recommend high protein treatment to improve clinical outcomes in critically ill patients diagnosed with preexisting malnutrition. However, this recommendation is based on expert opinion. RESEARCH QUESTION In critically ill patients, what is the association between preexisting malnutrition and time to discharge alive (TTDA), and does high protein treatment modify this association? STUDY DESIGN AND METHODS This multicenter randomized controlled trial involving 16 countries was designed to investigate the effects of high vs usual protein treatment in 1,301 critically ill patients. The primary outcome was TTDA. Multivariable regression was used to identify if preexisting malnutrition was associated with TTDA and if protein delivery modified their association. RESULTS The prevalence of preexisting malnutrition was 43.8%, and the cumulative incidence of live hospital discharge by day 60 was 41.2% vs 52.9% in the groups with and without preexisting malnutrition, respectively. The average protein delivery in the high vs usual treatment groups was 1.6 g/kg per day vs 0.9 g/kg per day. Preexisting malnutrition was independently associated with slower TTDA (adjusted hazard ratio, 0.81; 95% CI, 0.67-0.98). However, high protein treatment in patients with and without preexisting malnutrition was not associated with TTDA (adjusted hazard ratios of 0.84 [95% CI, 0.63-1.11] and 0.97 [95% CI, 0.77-1.21]). Furthermore, no effect modification was observed (ratio of adjusted hazard ratio, 0.84; 95% CI, 0.58-1.20). INTERPRETATION Malnutrition was associated with slower TTDA, but high protein treatment did not modify the association. These findings challenge current international critical care nutrition guidelines. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03160547; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, Singapore, Singapore; Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore, Singapore
| | - Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Xuran Jiang
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Danielle 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
| | - Gordon L Jensen
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Pauline Y Ng
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Adult Intensive Care Unit, Queen Mary Hospital, Hong Kong
| | - Lauren Tweel
- Clinical and Preventive Nutrition Sciences, Rutgers University, School of Health Professions, New Brunswick, NJ; Foothills Medical Centre, Calgary, AB, Canada
| | - Angela Parillo
- Department of Clinical Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Charlene Compher
- Department of Biobehavioral Health Science, University of Pennsylvania, School of Nursing, Philadelphia, PA.
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Hartl WH, Kopper P, Xu L, Heller L, Mironov M, Wang R, Day AG, Elke G, Küchenhoff H, Bender A. Relevance of Protein Intake for Weaning in the Mechanically Ventilated Critically Ill: Analysis of a Large International Database. Crit Care Med 2024; 52:e121-e131. [PMID: 38156913 PMCID: PMC10876180 DOI: 10.1097/ccm.0000000000006155] [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] [Indexed: 01/03/2024]
Abstract
OBJECTIVES The association between protein intake and the need for mechanical ventilation (MV) is controversial. We aimed to investigate the associations between protein intake and outcomes in ventilated critically ill patients. DESIGN Analysis of a subset of a large international point prevalence survey of nutritional practice in ICUs. SETTING A total of 785 international ICUs. PATIENTS A total of 12,930 patients had been in the ICU for at least 96 hours and required MV by the fourth day after ICU admission at the latest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We modeled associations between the adjusted hazard rate (aHR) of death in patients requiring MV and successful weaning (competing risks), and three categories of protein intake (low: < 0.8 g/kg/d, standard: 0.8-1.2 g/kg/d, high: > 1.2 g/kg/d). We compared five different hypothetical protein diets (an exclusively low protein intake, a standard protein intake given early (days 1-4) or late (days 5-11) after ICU admission, and an early or late high protein intake). There was no evidence that the level of protein intake was associated with time to weaning. However, compared with an exclusively low protein intake, a standard protein intake was associated with a lower hazard of death in MV: minimum aHR 0.60 (95% CI, 0.45-0.80). With an early high intake, there was a trend to a higher risk of death in patients requiring MV: maximum aHR 1.35 (95% CI, 0.99-1.85) compared with a standard diet. CONCLUSIONS The duration of MV does not appear to depend on protein intake, whereas mortality in patients requiring MV may be improved by a standard protein intake. Adverse effects of a high protein intake cannot be excluded.
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Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, and Transplantation Surgery, University Medical Center, Campus Grosshadern, LMU Munich, Munich, Germany
| | - Philipp Kopper
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
| | - Lisa Xu
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Luca Heller
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Maxim Mironov
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Ruiyi Wang
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
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5
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Wang L, Long Y, Zhang Z, Lin J, Zhou J, Li G, Ye B, Zhang H, Gao L, Tong Z, Li W, Ke L, Jiang Z. Association of energy delivery with short-term survival in mechanically ventilated critically ill adult patients: a secondary analysis of the NEED trial. Eur J Clin Nutr 2024; 78:257-263. [PMID: 38007601 DOI: 10.1038/s41430-023-01369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND AND AIMS The optimal energy delivery for mechanically ventilated patients is controversial, particularly during the first week of ICU admission. This study aimed to investigate the association between different caloric adequacy and 28-day mortality in a cohort of critically ill adults on mechanical ventilation. METHODS This is a secondary analysis of a multicenter, cluster-randomized controlled trial. Eligible patients were divided into four quartiles (Q1-Q4) according to caloric adequacy calculated by the actual average daily energy delivery during the first seven days of ICU stay divided by energy requirement as a percentage. Cox proportional hazards models were used to examine the impact of different quartiles of caloric adequacy on 28-day mortality in the whole cohort and subgroups with different nutritional risk status at enrollment. RESULTS A total of 1587 patients were included in this study, with an overall 28-day mortality of 15.8%. The average caloric adequacy was 26.3 ± 11.9% (Q1), 52.5 ± 5.5% (Q2), 71.7 ± 6.4% (Q3), 107.0 ± 22.2% (Q4), respectively (p < 0.001 among quartiles). Compared with Q1, Q3 was associated with lower mortality in the unadjusted model (hazard ratio [HR] = 0.536; 95% confidence interval [CI], 0.375-0.767; P = 0.001) and adjusted model (adjusted HR = 0.508; 95% CI, 0.339-0.761; P = 0.001). This association remained valid in the subgroup of high nutritional risk patients (unadjusted HR = 0.387; 95% CI, 0.238-0.627; P < 0.001 and adjusted HR = 0.369; 95% CI, 0.216-0.630; P < 0.001, respectively), but not in those with low risk. CONCLUSIONS Energy delivery near the 70% energy requirements in the first week of ICU stay was associated with reduced 28-day mortality among mechanically ventilated critically ill patients, especially in patients with high nutrition risk at admission.
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Affiliation(s)
- Lanting Wang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Long
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China
| | - Zixiong Zhang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Gang Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bo Ye
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - He Zhang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lin Gao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China.
| | - Zhengying Jiang
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China.
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Wang Y, Li Y, Li Y, Li H, Zhang D. Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding. Nutrition 2024; 117:112255. [PMID: 37897987 DOI: 10.1016/j.nut.2023.112255] [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: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023]
Abstract
Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.
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Affiliation(s)
- Youquan Wang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yanhua Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Yuting Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Hongxiang Li
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
| | - Dong Zhang
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, China.
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7
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van der Slikke EC, Beumeler LFE, Holmqvist M, Linder A, Mankowski RT, Bouma HR. Understanding Post-Sepsis Syndrome: How Can Clinicians Help? Infect Drug Resist 2023; 16:6493-6511. [PMID: 37795206 PMCID: PMC10546999 DOI: 10.2147/idr.s390947] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
Sepsis is a global health challenge, with over 49 million cases annually. Recent medical advancements have increased in-hospital survival rates to approximately 80%, but the escalating incidence of sepsis, owing to an ageing population, rise in chronic diseases, and antibiotic resistance, have also increased the number of sepsis survivors. Subsequently, there is a growing prevalence of "post-sepsis syndrome" (PSS). This syndrome includes long-term physical, medical, cognitive, and psychological issues after recovering from sepsis. PSS puts survivors at risk for hospital readmission and is associated with a reduction in health- and life span, both at short and long term, after hospital discharge. Comprehensive understanding of PSS symptoms and causative factors is vital for developing optimal care for sepsis survivors, a task of prime importance for clinicians. This review aims to elucidate our current knowledge of PSS and its relevance in enhancing post-sepsis care provided by clinicians.
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Affiliation(s)
- Elisabeth C van der Slikke
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
| | - Lise F E Beumeler
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, 8934AD, the Netherlands
- Department of Sustainable Health, Campus Fryslân, University of Groningen, Groningen, 8911 CE, the Netherlands
| | - Madlene Holmqvist
- Department of Infection Medicine, Skåne University Hospital Lund, Lund, 221 84, Sweden
| | - Adam Linder
- Department of Infection Medicine, Skåne University Hospital Lund, Lund, 221 84, Sweden
| | - Robert T Mankowski
- Department of Physiology and Aging, University of Florida, Gainesville, FL, 32610, USA
| | - Hjalmar R Bouma
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
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Hung KY, Chen TH, Lee YF, Fang WF. Using Body Composition Analysis for Improved Nutritional Intervention in Septic Patients: A Prospective Interventional Study. Nutrients 2023; 15:3814. [PMID: 37686846 PMCID: PMC10489810 DOI: 10.3390/nu15173814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
The study aimed to determine whether using body composition data acquired through bio-electrical impedance analysis (BIA) to adjust diet formulas could improve outcomes in septic patients. There were 132 septic patients in medical intensive care units enrolled in the prospective, randomized, double-blind, interventional study. For the intervention group, dietitians had access to BIA data for adjusting diet formulas according to body composition variables on days 1, 3, and 8. The patients were also stratified based on nutritional risk using the modified Nutrition Risk in Critically ill (mNUTRIC) score. Patients with intervention were more likely to achieve caloric and protein intake goals compared to the control group, especially in the low-risk group. The intervention did not significantly affect mortality, but the survival curves suggested potential benefits. The high-risk group had longer ICU stays and mechanical ventilation duration, which were mitigated by the intervention. Certain body composition variables (e.g., extracellular water to total body water ratio and phase angle) showed differences between high-risk and low-risk groups and may be related to patient outcomes. Non-invasive body composition assessment using BIA can help dietitians adjust diet formulas for critically ill septic patients. Body composition variables may be associated with sepsis outcomes, but further research with larger patient numbers is needed to confirm these findings.
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Affiliation(s)
- Kai-Yin Hung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
- Department of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan (Y.-F.L.)
- Department of Nursing, Mei Ho University, Pingtung 91202, Taiwan
| | - Tzu-Hsiu Chen
- Department of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan (Y.-F.L.)
| | - Ya-Fen Lee
- Department of Nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan (Y.-F.L.)
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 61363, Taiwan
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Reignier J, Plantefeve G, Mira JP, Argaud L, Asfar P, Aissaoui N, Badie J, Botoc NV, Brisard L, Bui HN, Chatellier D, Chauvelot L, Combes A, Cracco C, Darmon M, Das V, Debarre M, Delbove A, Devaquet J, Dumont LM, Gontier O, Groyer S, Guérin L, Guidet B, Hourmant Y, Jaber S, Lambiotte F, Leroy C, Letocart P, Madeux B, Maizel J, Martinet O, Martino F, Maxime V, Mercier E, Nay MA, Nseir S, Oziel J, Picard W, Piton G, Quenot JP, Reizine F, Renault A, Richecoeur J, Rigaud JP, Schneider F, Silva D, Sirodot M, Souweine B, Tamion F, Terzi N, Thévenin D, Thiery G, Thieulot-Rolin N, Timsit JF, Tinturier F, Tirot P, Vanderlinden T, Vinatier I, Vinsonneau C, Voicu S, Lascarrou JB, Le Gouge A. Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). THE LANCET. RESPIRATORY MEDICINE 2023; 11:602-612. [PMID: 36958363 DOI: 10.1016/s2213-2600(23)00092-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/10/2023] [Accepted: 02/27/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND The optimal calorie and protein intakes at the acute phase of severe critical illness remain unknown. We hypothesised that early calorie and protein restriction improved outcomes in these patients, compared with standard calorie and protein targets. METHODS The pragmatic, randomised, controlled, multicentre, open-label, parallel-group NUTRIREA-3 trial was performed in 61 French intensive care units (ICUs). Adults (≥18 years) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned to early nutrition (started within 24 h after intubation) with either low or standard calorie and protein targets (6 kcal/kg per day and 0·2-0·4 g/kg per day protein vs 25 kcal/kg per day and 1·0-1·3 g/kg per day protein) during the first 7 ICU days. The two primary endpoints were time to readiness for ICU discharge and day 90 all-cause mortality. Key secondary outcomes included secondary infections, gastrointestinal events, and liver dysfunction. The trial is registered on ClinicalTrials.gov, NCT03573739, and is completed. FINDINGS Of 3044 patients randomly assigned between July 5, 2018, and 8 Dec 8, 2020, eight withdrew consent to participation. By day 90, 628 (41·3%) of 1521 patients in the low group and 648 (42·8%) of 1515 patients in the standard group had died (absolute difference -1·5%, 95% CI -5·0 to 2·0; p=0·41). Median time to readiness for ICU discharge was 8·0 days (IQR 5·0-14·0) in the low group and 9·0 days (5·0-17·0) in the standard group (hazard ratio [HR] 1·12, 95% CI 1·02 to 1·22; p=0·015). Proportions of patients with secondary infections did not differ between the groups (HR 0·85, 0·71 to 1·01; p=0·06). The low group had lower proportions of patients with vomiting (HR 0·77, 0·67 to 0·89; p<0·001), diarrhoea (0·83, 0·73 to 0·94; p=0·004), bowel ischaemia (0·50, 0·26 to 0·95; p=0·030), and liver dysfunction (0·92, 0·86-0·99; p=0·032). INTERPRETATION Compared with standard calorie and protein targets, early calorie and protein restriction did not decrease mortality but was associated with faster recovery and fewer complications. FUNDING French Ministry of Health.
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Affiliation(s)
- Jean Reignier
- Movement, Interactions, Performance, UR 4334, Nantes Université, Nantes, France; Médecine Intensive Réanimation, CHU de Nantes, Hôtel-Dieu, Nantes, France.
| | - Gaetan Plantefeve
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Jean-Paul Mira
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Groupe Hospitalier Paris Centre-Université Paris Cité, AP-HP, Paris, France
| | - Laurent Argaud
- Service de Médecine Intensive Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, CHU Angers, Angers, France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Julio Badie
- Service de Médecine Intensive Réanimation, Hôpital Nord Franche Comté, Trevenans, France
| | - Nicolae-Vlad Botoc
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Malo, Saint-Malo, France
| | - Laurent Brisard
- Service d'Anesthésie RéanimationChirurgicale, Hôpital Laënnec, CHU de Nantes, Nantes, France
| | - Hoang-Nam Bui
- Service de Médecine Intensive Réanimation, CHU de Bordeaux, Bordeaux, France
| | - Delphine Chatellier
- Service de Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Louis Chauvelot
- Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Alain Combes
- Service de Médecine Intensive Réanimation, Sorbonne Université, Inserm, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Christophe Cracco
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Angoulême, Angoulême, France
| | - Michael Darmon
- Université Paris Cité, Service de Médecine Intensive Réanimation, CHU Saint Louis, AP-HP, Paris, France
| | - Vincent Das
- Service de Médecine Intensive Réanimation, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Matthieu Debarre
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Brieuc, Saint Brieuc, France
| | - Agathe Delbove
- Service de Réanimation Polyvalente, Centre Hospitalier Bretagne-Atlantique, Vannes, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Louis-Marie Dumont
- Service de Médecine Intensive Réanimation, Hôpital Louis-Mourier, AP-HP, Colombes, France
| | - Olivier Gontier
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Chartres, Chartres, France
| | - Samuel Groyer
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Montauban, Montauban, France
| | - Laurent Guérin
- Service de Médecine Intensive Réanimation, CHU Bicêtre, AP-HP, Paris, France
| | - Bertrand Guidet
- Sorbonne Université, Inserm, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Service de Médecine IntensiveRéanimation, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Yannick Hourmant
- CHU de Nantes, Inserm, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
| | - Samir Jaber
- Service de Réanimation Chirurgicale, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France; PhyMedExp, Inserm, CNRS, Montpellier, France
| | - Fabien Lambiotte
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Christophe Leroy
- Service de Médecine Intensive Réanimation, Centre Hospitalier Emile Roux, Le Puy-en-Velay, France
| | - Philippe Letocart
- Service de Médecine Intensive Réanimation, Centre Hospitalier Jacques Puel, Rodez, France
| | - Benjamin Madeux
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Bigorre, Tarbes, France
| | - Julien Maizel
- Service de Médecine Intensive Réanimation, CHU Amiens-Picardie, Amiens, France
| | - Olivier Martinet
- Service de Médecine Intensive Réanimation, CHU de la Réunion, Saint-Denis, La Réunion, France
| | - Frédéric Martino
- Service de Médecine Intensive Réanimation, CHU de la Guadeloupe, Abymes, Guadeloupe, France
| | - Virginie Maxime
- Service de Médecine Intensive Réanimation, Hôpital Raymond Poincaré, AP-HP, Garches, France; Inserm U 1173, Université de Versailles-Saint Quentin en Yvelines, Versailles, France
| | - Emmanuelle Mercier
- Service de Médecine Intensive Réanimation, CHU de Tours, CRICS-TRIGGERSEP Network Tours, France
| | - Mai-Anh Nay
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France
| | - Saad Nseir
- Médecine Intensive-Réanimation, CHU Lille, France; CNRS, Inserm, UMR 8576-U1285, Unité de Glycobiologie Structurale et Fonctionnelle, Université de Lille, France
| | - Johanna Oziel
- Service de Médecine Intensive Réanimation, Hôpital Avicenne, AP-HP, Bobigny, France
| | - Walter Picard
- Service deMédecine Intensive Réanimation, Centre Hospitalier de Pau, Pau, France
| | - Gael Piton
- Service de Médecine Intensive Réanimation, CHU de Besançon, Besançon, France; Université de Franche Comté, Equipe EA 3920, Besançon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, CHU François Mitterrand, Dijon, France; Lipness Team, Inserm, LabExLipSTIC France; Inserm Centres d'Investigation Clinique, Département d'Epidémiologie Clinique, Université de Bourgogne, Dijon, France
| | - Florian Reizine
- Service de Médecine Intensive Réanimation, CHU de Rennes, Rennes, France
| | - Anne Renault
- Service de Médecine Intensive Réanimation, CHU la Cavale Blanche, Brest, France
| | - Jack Richecoeur
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Beauvais, Beauvais, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Francis Schneider
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Daniel Silva
- Service de Médecine Intensive Réanimation, Hôpital Delafontaine, Saint-Denis, France
| | - Michel Sirodot
- Service de Médecine Intensive Réanimation, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Bertrand Souweine
- Service de Médecine Intensive Réanimation, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Fabienne Tamion
- Service de Médecine Intensive Réanimation, Hôpital Charles Nicolle, CHU de Rouen, Normandie Université, UNIROUEN, Inserm U1096, FHU REMOD-VHF, Rouen, France
| | - Nicolas Terzi
- Service de Médecine Intensive Réanimation, Université de Grenoble-Alpes, Inserm U1042, Grenoble, France
| | - Didier Thévenin
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Lens, Lens, France
| | - Guillaume Thiery
- Service de Médecine Intensive Réanimation, CHU de Saint Étienne, Saint Priest en Jarez, France
| | - Nathalie Thieulot-Rolin
- Service de Médecine Intensive Réanimation, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Jean-Francois Timsit
- Service de Médecine Intensive Réanimation, CHU Bichat-Claude Bernard, AP-HP, Paris, France; Université Paris-Cité, Inserm IAME, U1137, Team DesCID, Paris, France
| | - Francois Tinturier
- Service de Réanimation Chirurgicale, CHU Amiens-Picardie, Amiens, France
| | - Patrice Tirot
- Service de Médecine Intensive Réanimation, Centre Hospitalier du Mans, Le Mans, France
| | - Thierry Vanderlinden
- Service de Médecine Intensive Réanimation, Groupement Hospitalier de l'Institut Catholique de Lille, FMMS-ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Isabelle Vinatier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche sur Yon, France
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Béthune, France
| | - Sebastian Voicu
- Service de Médecine Intensive Réanimation, CHU Lariboisière, AP-HP, Paris, France
| | - Jean-Baptiste Lascarrou
- Movement, Interactions, Performance, UR 4334, Nantes Université, Nantes, France; Médecine Intensive Réanimation, CHU de Nantes, Hôtel-Dieu, Nantes, France
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Pierre A, Bourel C, Favory R, Brassart B, Wallet F, Daussin FN, Normandin S, Howsam M, Romien R, Lemaire J, Grolaux G, Durand A, Frimat M, Bastide B, Amouyel P, Boulanger E, Preau S, Lancel S. Sepsis-like Energy Deficit Is Not Sufficient to Induce Early Muscle Fiber Atrophy and Mitochondrial Dysfunction in a Murine Sepsis Model. BIOLOGY 2023; 12:529. [PMID: 37106730 PMCID: PMC10136327 DOI: 10.3390/biology12040529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/17/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023]
Abstract
Sepsis-induced myopathy is characterized by muscle fiber atrophy, mitochondrial dysfunction, and worsened outcomes. Whether whole-body energy deficit participates in the early alteration of skeletal muscle metabolism has never been investigated. Three groups were studied: "Sepsis" mice, fed ad libitum with a spontaneous decrease in caloric intake (n = 17), and "Sham" mice fed ad libitum (Sham fed (SF), n = 13) or subjected to pair-feeding (Sham pair fed (SPF), n = 12). Sepsis was induced by the intraperitoneal injection of cecal slurry in resuscitated C57BL6/J mice. The feeding of the SPF mice was restricted according to the food intake of the Sepsis mice. Energy balance was evaluated by indirect calorimetry over 24 h. The tibialis anterior cross-sectional area (TA CSA), mitochondrial function (high-resolution respirometry), and mitochondrial quality control pathways (RTqPCR and Western blot) were assessed 24 h after sepsis induction. The energy balance was positive in the SF group and negative in both the SPF and Sepsis groups. The TA CSA did not differ between the SF and SPF groups, but was reduced by 17% in the Sepsis group compared with the SPF group (p < 0.05). The complex-I-linked respiration in permeabilized soleus fibers was higher in the SPF group than the SF group (p < 0.05) and lower in the Sepsis group than the SPF group (p < 0.01). Pgc1α protein expression increased 3.9-fold in the SPF mice compared with the SF mice (p < 0.05) and remained unchanged in the Sepsis mice compared with the SPF mice; the Pgc1α mRNA expression decreased in the Sepsis compared with the SPF mice (p < 0.05). Thus, the sepsis-like energy deficit did not explain the early sepsis-induced muscle fiber atrophy and mitochondrial dysfunction, but led to specific metabolic adaptations not observed in sepsis.
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Affiliation(s)
- Alexandre Pierre
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Claire Bourel
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Raphael Favory
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Benoit Brassart
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Frederic Wallet
- Division of Bacteriology, Biology Pathology Institute of Lille, CHU de Lille, F-59000 Lille, France
| | - Frederic N. Daussin
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, ULR 7369-URePSSS-Unité de Recherche Pluridisciplinaire Sport Santé Société, F-59000 Lille, France
| | - Sylvain Normandin
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Michael Howsam
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Raphael Romien
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Jeremy Lemaire
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Gaelle Grolaux
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Arthur Durand
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Marie Frimat
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Nephrology, CHU de Lille, Université de Lille, F-59000 Lille, France
| | - Bruno Bastide
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, ULR 7369-URePSSS-Unité de Recherche Pluridisciplinaire Sport Santé Société, F-59000 Lille, France
| | - Philippe Amouyel
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Eric Boulanger
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
| | - Sebastien Preau
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
- Division of Intensive Care, Hôpital Roger Salengro, CHU de Lille, F-59000 Lille, France
| | - Steve Lancel
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1167-RID-AGE-Facteurs de Risque et Déterminants Moléculaires des Maladies Liées au Vieillissement, F-59000 Lille, France
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Inflammation and Nutrition: Friend or Foe? Nutrients 2023; 15:nu15051159. [PMID: 36904164 PMCID: PMC10005147 DOI: 10.3390/nu15051159] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
The importance of the interplay between inflammation and nutrition has generated much interest in recent times. Inflammation has been identified as a key driver for disease-related malnutrition, leading to anorexia, reduced food intake, muscle catabolism, and insulin resistance, which are stimulating a catabolic state. Interesting recent data suggest that inflammation also modulates the response to nutritional treatment. Studies have demonstrated that patients with high inflammation show no response to nutritional interventions, while patients with lower levels of inflammation do. This may explain the contradictory results of nutritional trials to date. Several studies of heterogeneous patient populations, or in the critically ill or advanced cancer patients, have not found significant benefits on clinical outcome. Vice versa, several dietary patterns and nutrients with pro- or anti-inflammatory properties have been identified, demonstrating that nutrition influences inflammation. Within this review, we summarize and discuss recent advances in both the role of inflammation in malnutrition and the effect of nutrition on inflammation.
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Medical Nutrition Therapy in Critically Ill Patients with COVID-19-A Single-Center Observational Study. Nutrients 2023; 15:nu15051086. [PMID: 36904086 PMCID: PMC10005698 DOI: 10.3390/nu15051086] [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: 12/21/2022] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris-Benedict equation (HB), the Mifflin-St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.
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Ochoa Gautier JB, Berger A, Hussein R, Huhmann MB. Safety of increasing protein delivery with an enteral nutrition formula containing very high protein (VHP) and lower carbohydrate concentrations compared to conventional standard (SF) and high protein (HP) formulas. Clin Nutr 2022; 41:2833-2842. [PMID: 36402010 DOI: 10.1016/j.clnu.2022.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND & AIMS Studies demonstrate that caloric restriction in the first seven days in the ICU is safe. The amount of protein that should be delivered, however, is still unclear with clinical trials suggesting mixed results. Despite some capacity to customize the delivery of protein using supplemental modules, protein delivered is best determined by the concentration of protein contained in enteral formula (EF) ordered. This fact provides an opportunity to explore the potential clinical effects of protein delivery and lower carbohydrate intake on clinical outcomes compared with conventional enteral formulas. METHODS Retrospective analysis of clinical outcomes according to the amount of protein delivered in critically ill patients admitted to intensive care units at Geisinger Health System. RESULTS 2000 encounters (1899 patients) in patients on enteral nutrition were divided into three groups receiving EF with either ≤20% protein (standard formula - SF), 21-25% protein (high protein - HP) or > 25% protein (VHP). Protein intake increased up to day 7 (p < 0.0001). Patients on VHP received more protein than other groups (p < 0.0001). Multivariable regression analysis showed no evidence of harm. In fact, we observed increased mortality with SF and HP formulas at 30-days post-discharge when compared to patients on VHP even when the effects of other variables (including age, BMI, sex, primary diagnosis, diabetes, history of dialysis, ICU days kept NPO) were taken into consideration. CONCLUSIONS Increasing protein intake while reducing carbohydrate intake appears to be safe. Further research aimed at defining a causative effect of increasing protein delivery while reducing carbohydrate load on outcomes is warranted.
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Affiliation(s)
| | - Andrea Berger
- Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822, USA
| | - Raghad Hussein
- Geisinger Medical Center, 100 N. Academy Drive, Danville, PA 17822, USA
| | - Maureen B Huhmann
- Nestle Health Science, 1007 US Highway 202/206, Building JR2, Bridgewater, NJ 08807, USA
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Lee ZY, Loh CTI, Lew CCH, Ke L, Heyland DK, Hasan MS. Nutrition therapy in the older critically ill patients: A scoping review. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Introduction: There is a lack of guidelines or formal systematic synthesis of evidence for nutrition therapy in older critically ill patients. This study is a scoping review to explore the state of evidence in this population.
Method: MEDLINE and Embase were searched from inception until 9 February 2022 for studies that enrolled critically ill patients aged ≥60 years and investigated any area of nutrition therapy. No language or study design restrictions were applied.
Results: Thirty-two studies (5 randomised controlled trials) with 6 topics were identified: (1) nutrition screening and assessments, (2) muscle mass assessment, (3) route or timing of nutrition therapy, (4) determination of energy and protein requirements, (5) energy and protein intake, and (6) pharmaconutrition. Topics (1), (3) and (6) had similar findings among general adult intensive care unit (ICU) patients. Skeletal muscle mass at ICU admission was significantly lower in older versus young patients. Among older ICU patients, low muscularity at ICU admission increased the risk of adverse outcomes. Predicted energy requirements using weight-based equations significantly deviated from indirect calorimetry measurements in older vs younger patients. Older ICU patients required higher protein intake (>1.5g/kg/day) than younger patients to achieve nitrogen balance. However, at similar protein intake, older patients had a higher risk of azotaemia.
Conclusion: Based on limited evidence, assessment of muscle mass, indirect calorimetry and careful monitoring of urea level may be important to guide nutrition therapy in older ICU patients. Other nutrition recommendations for general ICU patients may be used for older patients with sound clinical discretion.
Keywords: Critical care nutrition, geriatric patients, intensive care medicine, older adults, scoping review
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Affiliation(s)
| | | | | | - Lu Ke
- Medical School of Nanjing, Nanjing, China
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15
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The Impact of Higher Protein Intake in Patients with Prolonged Mechanical Ventilation. Nutrients 2022; 14:nu14204395. [PMID: 36297079 PMCID: PMC9610994 DOI: 10.3390/nu14204395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
Prolonged mechanical ventilation (PMV) is associated with poor outcomes and a high economic cost. The association between protein intake and PMV has rarely been investigated in previous studies. This study aimed to investigate the impact of protein intake on weaning from mechanical ventilation. Patients with the PMV (mechanical ventilation ≥6 h/day for ≥21 days) at our hospital between December 2020 and April 2022 were included in this study. Demographic data, nutrition records, laboratory data, weaning conditions, and survival data were retrieved from the patient’s electronic medical records. A total of 172 patients were eligible for analysis. The patients were divided into two groups: weaning success (n = 109) and weaning failure (n = 63). Patients with daily protein intake greater than 1.2 g/kg/day had significant shorter median days of ventilator use than those with less daily protein intake (36.5 vs. 114 days, respectively, p < 0.0001). Daily protein intake ≥1.065 g/kg/day (odds ratio: 4.97, p = 0.033), daily protein intake ≥1.2 g/kg/day (odds ratio: 89.07, p = 0.001), improvement of serum albumin (odds ratio: 3.68, p = 0.027), and BMI (odds ratio: 1.235, p = 0.014) were independent predictor for successful weaning. The serum creatinine level in the 4th week remained similar in patients with daily protein intake either >1.065 g/kg/day or >1.2 g/kg/day (p = 0.5219 and p = 0.7796, respectively). Higher protein intake may have benefits in weaning in patients with PMV and had no negative impact on renal function.
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16
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Park H, Lim SY, Kim S, Kim HS, Kim S, Yoon HI, Cho YJ. Effect of a nutritional support protocol on enteral nutrition and clinical outcomes of critically ill patients: a retrospective cohort study. Acute Crit Care 2022; 37:382-390. [PMID: 35977898 PMCID: PMC9475161 DOI: 10.4266/acc.2022.00220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background Enteral nutrition (EN) supply within 48 hours after intensive care unit (ICU) admission improves clinical outcomes. The “new ICU evaluation & development of nutritional support protocol (NICE-NST)” was introduced in an ICU of tertiary academic hospital. This study showed that early EN through protocolized nutritional support would supply more nutrition to improve clinical outcomes. Methods This study screened 170 patients and 62 patients were finally enrolled; patients who were supplied nutrition without the protocol were classified as the control group (n=40), while those who were supplied according to the protocol were classified as the test group (n=22). Results In the test group, EN started significantly earlier (3.7±0.4 days vs. 2.4±0.5 days, P=0.010). EN calorie (4.0±1.0 kcal/kg vs. 6.7±0.9 kcal/kg, P=0.006) and protein (0.17±0.04 g/kg vs. 0.32±0.04 g/kg, P=0.002) supplied were significantly higher in the test group. Although EN was supplied through continuous feeding in the test group, there was no difference in complications such as feeding hold due to excessive gastric residual volume or vomit, and hyper- or hypo-glycemia between the two groups. Hospital mortality was significantly lower in the group that started EN within 1.5 days (42.9% vs. 11.8%, P=0.018). The proportion of patients who started EN within 1.5 days was higher in the test group (40.9% vs. 17.5%, P=0.044). Conclusions The NICE-NST may improve EN supply and mortality of critically ill patients without increasing complications.
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Chawla R, Gangopadhyay K, Lathia T, Punyani H, Kanungo A, Sahoo A, Seshadri K. Management of hyperglycemia in critical care. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_69_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Al-Dorzi HM, Arabi YM. Nutrition support for critically ill patients. JPEN J Parenter Enteral Nutr 2021; 45:47-59. [PMID: 34897737 DOI: 10.1002/jpen.2228] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Hasan M Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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19
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Wang D, Lin Z, Xie L, Huang K, Ji Z, Gu C, Wang S. Impact of early protein provision on the mortality of acute critically ill stroke patients. Nutr Clin Pract 2021; 37:861-868. [PMID: 34582584 DOI: 10.1002/ncp.10768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Stroke is the leading cause of death in China, and dysphagia is a common symptom of stroke. For acute critically ill stroke patients, whether the protein provision overwhelming calorie provision impacts the outcome still requires investigation. MATERIALS AND METHODS We conducted a retrospectively observational study. Acute stroke patients admitted to our neurocritical care unit between January 2013 and January 2017 were enrolled. Primary end points were short-term (30-day) and long-term (6-month) mortality, as well as long-term poor outcome with a modified Rankin scale score ≥4. RESULTS Of 208 eligible patients, 127 (61.1%) patients were diagnosed with acute ischemic stroke and 81 (38.9%) with intracranial hemorrhage. In multivariate logistic regression analysis, the increased protein provision was significantly associated with reduced 30-day and 6-month mortality (P = .041 and P = .020, respectively) but not 6-month functional outcome (P = .365), whereas calorie provision had no independent association with either mortality or functional outcome. When the protein provision ≤1.74 g/kg/day, there was a 9.37% decrease in short-term mortality and a 9.21% decrease in long-term mortality with each 0.1 g/kg/day increase in protein delivery. The patients were further divided into five subgroups based on the amount of protein provision, and Linear-by-Linear Association tests showed there was a negative linear relationship between the protein provision and 30-day and 6-month mortality (P = .048 and P = .017, respectively). CONCLUSIONS Early protein provision during the first week is an independent predictor of short-term and long-term mortality in acute critically ill stroke patients.
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Affiliation(s)
- Dongmei Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhou Lin
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Xie
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Kaibin Huang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhong Ji
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chunping Gu
- Pharmaceutics Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Serón Arbeloa C, Martínez de la Gándara A, León Cinto C, Flordelís Lasierra JL, Márquez Vácaro JA. Recommendations for specialized nutritional-metabolic management of the critical patient: Macronutrient and micronutrient requirements. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:24-32. [PMID: 32532407 DOI: 10.1016/j.medin.2019.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/02/2019] [Accepted: 12/21/2019] [Indexed: 01/15/2023]
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Reignier J, Le Gouge A, Lascarrou JB, Annane D, Argaud L, Hourmant Y, Asfar P, Badie J, Nay MA, Botoc NV, Brisard L, Bui HN, Chatellier D, Chauvelot L, Combes A, Cracco C, Darmon M, Das V, Debarre M, Delbove A, Devaquet J, Voicu S, Aissaoui-Balanant N, Dumont LM, Oziel J, Gontier O, Groyer S, Guidet B, Jaber S, Lambiotte F, Leroy C, Letocart P, Madeux B, Maizel J, Martinet O, Martino F, Mercier E, Mira JP, Nseir S, Picard W, Piton G, Plantefeve G, Quenot JP, Renault A, Guérin L, Richecoeur J, Rigaud JP, Schneider F, Silva D, Sirodot M, Souweine B, Reizine F, Tamion F, Terzi N, Thévenin D, Thiéry G, Thieulot-Rolin N, Timsit JF, Tinturier F, Tirot P, Vanderlinden T, Vinatier I, Vinsonneau C, Maugars D, Giraudeau B. Impact of early low-calorie low-protein versus standard-calorie standard-protein feeding on outcomes of ventilated adults with shock: design and conduct of a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). BMJ Open 2021; 11:e045041. [PMID: 33980526 PMCID: PMC8117996 DOI: 10.1136/bmjopen-2020-045041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION International guidelines include early nutritional support (≤48 hour after admission), 20-25 kcal/kg/day, and 1.2-2 g/kg/day protein at the acute phase of critical illness. Recent data challenge the appropriateness of providing standard amounts of calories and protein during acute critical illness. Restricting calorie and protein intakes seemed beneficial, suggesting a role for metabolic pathways such as autophagy, a potential key mechanism in safeguarding cellular integrity, notably in the muscle, during critical illness. However, the optimal calorie and protein supply at the acute phase of severe critical illness remains unknown. NUTRIREA-3 will be the first trial to compare standard calorie and protein feeding complying with guidelines to low-calorie low-protein feeding. We hypothesised that nutritional support with calorie and protein restriction during acute critical illness decreased day 90 mortality and/or dependency on intensive care unit (ICU) management in mechanically ventilated patients receiving vasoactive amine therapy for shock, compared with standard calorie and protein targets. METHODS AND ANALYSIS NUTRIREA-3 is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients receiving invasive mechanical ventilation and vasoactive amine therapy for shock and given early nutritional support according to one of two strategies: early calorie-protein restriction (6 kcal/kg/day-0.2-0.4 g/kg/day) or standard calorie-protein targets (25 kcal/kg/day, 1.0-1.3 g/kg/day) at the acute phase defined as the first 7 days in the ICU. We will include 3044 patients in 61 French ICUs. Two primary end-points will be evaluated: day 90 mortality and time to ICU discharge readiness. The trial will be considered positive if significant between-group differences are found for one or both alternative primary endpoints. Secondary outcomes include hospital-acquired infections and nutritional, clinical and functional outcomes. ETHICS AND DISSEMINATION The NUTRIREA-3 study has been approved by the appropriate ethics committee. Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03573739.
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Affiliation(s)
- Jean Reignier
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Amélie Le Gouge
- INSERM CIC 1415, Centre Hospitalier Regional Universitaire de Tours, Tours, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Djillali Annane
- Service de Médecine Intensive Réanimation, Hôpital Raymond Poincaré, Garches, France
| | - Laurent Argaud
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Yannick Hourmant
- Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, CHU Nantes, Nantes, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Julio Badie
- Service de Médecine Intensive Réanimation, Hôpital Nord Franche-Comté, Montbeliard, France
| | - Mai-Anh Nay
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orleans Hôpital de La Source, Orleans, France
| | - Nicolae-Vlad Botoc
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint-Malo, Saint-Malo, France
| | - Laurent Brisard
- Service d'Anesthésie Réanimation Chirurgicale, CHU Nantes, Nantes, France
| | - Hoang-Nam Bui
- Service de Médecine Intensive Réanimation, CHU de Bordeaux, Bordeaux, France
| | | | - Louis Chauvelot
- Service de Médecine Intensive Réanimation, CHU Lyon, Lyon, France
| | - Alain Combes
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Christophe Cracco
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Angouleme, Angouleme, France
| | - Michael Darmon
- Service de Médecine Intensive Réanimation, Hôpital Saint-Louis, Paris, France
| | - Vincent Das
- Médecine Intensive Réanimation, CHI André Grégoire, Montreuil, France
| | - Matthieu Debarre
- Médecine Intensive Réanimation, Centre Hospitalier de Saint Brieuc, Saint Brieuc, France
| | - Agathe Delbove
- Réanimation Polyvalente, Centre Hospitalier Bretagne Atlantique, Vannes, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Sebastian Voicu
- Médecine Intensive Réanimation, Hopital Lariboisiere, Paris, France
| | - Nadia Aissaoui-Balanant
- Médecine Intensive Réanimation, Hôpital Europeen Georges-Pompidou - Broussais, Paris, France
| | - Louis-Marie Dumont
- Service de Médecine Intensive Réanimation, Hôpital Louis-Mourier, Colombes, France
| | - Johanna Oziel
- Service de Médecine Intensive Réanimation, Hôpital Avicenne, Bobigny, France
| | - Olivier Gontier
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Chartres, Chartres, France
| | - Samuel Groyer
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Montauban, Montauban, France
| | - Bertrand Guidet
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Paris, France
| | - Samir Jaber
- Service de Réanimation Chirurgicale, Hôpital Saint-Eloi, Montpellier, France
| | - Fabien Lambiotte
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Christophe Leroy
- Service de Médecine Intensive Réanimation, Centre Hospitalier Emile Roux, Le Puy en Velay, France
| | - Philippe Letocart
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Rodez, Rodez, France
| | - Benjamin Madeux
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Bigorre, Tarbes, France
| | - Julien Maizel
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - Olivier Martinet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de La Réunion, Saint-Denis, France
| | - Frédéric Martino
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Pointe-à-Pitre Abymes, Pointe-a-Pitre, Guadeloupe
| | - Emmanuelle Mercier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Jean-Paul Mira
- Service de Médecine Intensive Réanimation, Hôpital Cochin, Paris, France
| | - Saad Nseir
- Service de Médecine Intensive Réanimation, CHU Lille, Lille, France
| | - Walter Picard
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Pau, Pau, France
| | - Gael Piton
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Besancon, Besancon, France
| | - Gaetan Plantefeve
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Anne Renault
- Service de Médecine Intensive Réanimation, CHRU de Brest, Brest, France
| | - Laurent Guérin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bicêtre, Le Kremlin-Bicetre, France
| | - Jack Richecoeur
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Beauvais, Beauvais, France
| | - Jean Philippe Rigaud
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Francis Schneider
- Service de Médecine Intensive Réanimation, Hopitaux Universitaires de Strasbourg, Strasbourg, France
| | - Daniel Silva
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint Denis, Saint Denis, France
| | - Michel Sirodot
- Service de Médecine Intensive Réanimation, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Bertrand Souweine
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Florian Reizine
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Fabienne Tamion
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Nicolas Terzi
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire Grenoble Alpes Hopital Michallon, La Tronche, France
| | - Didier Thévenin
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Lens, Lens, France
| | - Guillaume Thiéry
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | | | - Jean-François Timsit
- Service de Médecine Intensive Réanimation, Hôpital Bichat - Claude-Bernard, Paris, France
| | - François Tinturier
- Réanimation Chirurgicale, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - Patrice Tirot
- Service de Médecine Intensive Réanimation, Centre Hospitalier du Mans, Le Mans, France
| | - Thierry Vanderlinden
- Service de Médecine Intensive Réanimation, Institut Catholique de Lille, Lille, France
| | - Isabelle Vinatier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Départemental Vendée, La Roche-sur-Yon, France
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Bethune, France
| | - Diane Maugars
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Bruno Giraudeau
- INSERM CIC 1415, Centre Hospitalier Regional Universitaire de Tours, Tours, France
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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The anabolic role of the Warburg, Cori-cycle and Crabtree effects in health and disease. Clin Nutr 2021; 40:2988-2998. [PMID: 33674148 DOI: 10.1016/j.clnu.2021.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
In evolution, genes survived that could code for metabolic pathways, promoting long term survival during famines or fasting when suffering from trauma, disease or during physiological growth. This requires utilization of substrates, already present in some form in the body. Carbohydrate stores are limited and to survive long, their utilization is restricted to survival pathways, by inhibiting glucose oxidation and glycogen synthesis. This leads to insulin resistance and spares muscle protein, because being the main supplier of carbon for new glucose production. In these survival pathways, part of the glucose is degraded in glycolysis in peripheral (muscle) tissues to pyruvate and lactate (Warburg effect), which are partly reutilized for glucose formation in liver and kidney, completing the Cori-cycle. Another part of the glucose taken up by muscle contributes, together with muscle derived amino acids, to the production of substrates consisting of a complete amino acid mix but extra non-essential amino acids like glutamine, alanine, glycine and proline. These support cell proliferation, matrix deposition and redox regulation in tissues, specifically active in host response and during growth. In these tissues, also glucose is taken up delivering glycolytic intermediates, that branch off and act as building blocks and produce reducing equivalents. Lactate is also produced and released in the circulation, adding to the lactate released by muscle in the Cori-cycle and completing secondary glucose cycles. Increased fluxes through these cycles lead to modest hyperglycemia and hyperlactatemia in states of healthy growth and disease and are often misinterpreted as induced by hypoxia.
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Energy and protein intake in critically ill people with respiratory failure treated by high-flow nasal-cannula oxygenation: An observational study. Nutrition 2020; 84:111117. [PMID: 33486298 DOI: 10.1016/j.nut.2020.111117] [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: 07/27/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES High-flow nasal-cannula (HFNC) oxygen therapy is increasingly used in the management of respiratory distress. Since this treatment may be required for many days and may impair nutritional intake, this study planned to observe the energy and protein intake of individuals receiving this therapy. METHODS Forty consecutive patients requiring HFNC oxygenation after extubation or to prevent intubation from November 2017 to June 2018 were included in the study. Demographics, route of nutrition (oral, enteral, or parenteral), calories and protein prescribed and administered, and complications were noted until discharge. Statistical analysis used χ2 or Kruskal-Wallis H test. RESULTS HFNC oxygen therapy was applied for 42 d in the 40 participants. Overall, individuals with HFNC oxygenation therapy received 449.5 (interquartile range [IQR], 312-850) kcal/d and 19.25 (IQR, 13.9-33.3) g/d protein. Twenty-one participants treated with enteral nutrition received 387 (IQR, 273-931) kcal/d and 18.5 (IQR, 13.9-33.3) g/d protein, whereas those with oral feeding (n = 13) received higher totals of calories, 600 (IQR, 459-850) kcal/d (P = 0.056), and protein, 22 (IQR, 20-45) g/d (P = 0.005). Four participants received parenteral nutrition alone, providing 543 (IQR, 375-886.5) kcal/d and 8.7 (IQR, 0-20) g/d protein. When parenteral nutrition was administered with enteral nutrition, it provided only 324 (IQR, 290-358) kcal/d. Two participants did not receive any nutritional support. The overall length of stay in the intensive care unit was 8 (IQR, 5-17.5) d. Participants receiving enteral nutrition had a longer stay (14 d; IQR, 8-20) than the oral-diet group (4 d; IQR, 2-10; P < 0.03). The rate of intubation after HFNC therapy was not significantly different between the groups (P = 0.586). CONCLUSIONS Administration of HFNC oxygen therapy was associated with significant underfeeding. In order to reach optimal caloric and protein intake, parenteral nutrition may be considered.
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Peçanha Antonio AC, Loss SH, Viana LV. Too Many Calories for All? Am J Respir Crit Care Med 2020; 202:1059-1060. [PMID: 32516541 PMCID: PMC7528784 DOI: 10.1164/rccm.202004-1496le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Sergio Henrique Loss
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil and.,Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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McKendry J, Thomas ACQ, Phillips SM. Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies. Nutr Clin Pract 2020; 35:607-616. [PMID: 32578900 DOI: 10.1002/ncp.10540] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022] Open
Abstract
Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.
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Affiliation(s)
- James McKendry
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Aaron C Q Thomas
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Stuart M Phillips
- Exercise Metabolism Research Group, Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
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Tatucu-Babet OA, Fetterplace K, Lambell K, Miller E, Deane AM, Ridley EJ. Is Energy Delivery Guided by Indirect Calorimetry Associated With Improved Clinical Outcomes in Critically Ill Patients? A Systematic Review and Meta-analysis. Nutr Metab Insights 2020; 13:1178638820903295. [PMID: 32231435 PMCID: PMC7082874 DOI: 10.1177/1178638820903295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/03/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Indirect calorimetry (IC) is recommended to guide energy delivery over predictive equations in critical illness due to its precision. However, the impact of using IC to measure energy expenditure on clinical outcomes is uncertain. Objective: To evaluate whether using IC to measure energy expenditure to inform energy delivery reduced hospital mortality and improved other important outcomes compared to using predictive equations in critically ill adults. Methods: A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Medline, Embase, CINAHL, and the Cochrane Library were searched for studies using IC to guide energy delivery compared to a predictive equation in adult critically ill patients with the primary outcome (hospital mortality) or any of the secondary outcomes reported (including but not limited to hospital and intensive care unit (ICU) length of stay (LOS) and duration mechanical ventilation (MV). Risk of bias within studies was assessed using the Cochrane “Risk of Bias” 1 tool. Random-effect meta-analyses were used when heterogeneity between studies existed (I2 > 50%). Data are reported as median (interquartile range [IQR]), binomial outcomes as odds ratio (OR), 95% confidence interval (CI), and continuous outcomes as mean difference (MD). Results: Of 4060 articles, 4 randomized controlled trials were identified with 396 patients included in analysis. Three studies were considered low risk of bias and 1 as high risk. Two studies reported hospital mortality (n = 130 and 40 participants, respectively). When combined, no association between IC-guided energy delivery and hospital mortality was found (OR = 0.81, 95% CI = [0.25, 2.67], P = 0.73, I2 = 52). No differences were reported with ICU mortality and hospital LOS between groups, but ICU LOS and duration of MV varied across all studies. According to the meta-analysis, no differences were observed in ICU LOS (MD = 1.39, 95% CI = [–5.01, 7.79], P = 0.67, I2 = 81%), although the duration of MV was increased when energy delivery was guided by IC (MD = 2.01, 95% CI = [0.45, 3.57], P = 0.01, I2 = 26%). In all 4 studies, prescribed energy targets were more closely met when energy delivery was informed by IC compared to a predictive equation. Three studies reported the percentage delivered versus the prescribed energy target, with the median (IQR) delta between the IC and predictive equation arms 19% (10%-32%). Conclusion: Limited data exist to assess the impact of using IC to inform energy delivery in comparison to predictive equations on hospital mortality. The association of IC use with other important outcomes, including duration of MV, needs to be further explored before definitive conclusions can be made.
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Affiliation(s)
- Oana A Tatucu-Babet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Kate Fetterplace
- Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Kate Lambell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Eliza Miller
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Adam M Deane
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Nutrition Department, The Alfred Hospital, Melbourne, VIC, Australia
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Jiang L, Huang X, Wu C, Tang J, Li Q, Feng X, He T, Wang Z, Gao J, Ruan Z, Hong W, Lai D, Zhao F, Huang Z, Lu Z, Tang W, Zhu L, Zhang B, Wang Z, Shen X, Lai J, Ji Z, Fu K, Hong Y, Dai J, Hong G, Xu W, Wang Y, Xie Y, Chen Y, Zhu X, Ding G, Gu L, Zhang M. The effects of an enteral nutrition feeding protocol on critically ill patients: A prospective multi-center, before-after study. J Crit Care 2020; 56:249-256. [PMID: 31986368 DOI: 10.1016/j.jcrc.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/05/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients. METHODS This was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission. RESULTS 209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost. CONCLUSION The implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate. Trial registration ClinicalTrials.gov, NCT02976155. Registered November 29, 2016- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02976155.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiaoxia Huang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Chunshuang Wu
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Jiaying Tang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Qiang Li
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiuqin Feng
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Tao He
- Department of Emergency Intensive Care Unit, The Second Hospital of Jiaxing, No 1518, Huanchengbei Rd, Jiaxing, China
| | - Zhengquan Wang
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Jindan Gao
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Zhanwei Ruan
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Weili Hong
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Dengpan Lai
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Fei Zhao
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhiping Huang
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Zhifeng Lu
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Weidong Tang
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Lijun Zhu
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Bingwen Zhang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Zhi Wang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Xiaoyuan Shen
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Jiawei Lai
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Zhaohui Ji
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Kai Fu
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junru Dai
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guangliang Hong
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenqing Xu
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi Wang
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yun Xie
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yuxi Chen
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Xiuhua Zhu
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Guojuan Ding
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Lanru Gu
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Mao Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China.
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Zhou X, Fang H, Hu C, Xu J, Wang H, Pan J, Sha Y, Xu Z. [Effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults - A meta-analysis of randomized controlled trials with trial sequential analysis]. Med Intensiva 2019; 45:211-225. [PMID: 31784295 DOI: 10.1016/j.medin.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/02/2019] [Accepted: 10/07/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To compare the effect of hypocaloric versus standard enteral feeding on clinical outcomes in critically ill adults, and to investigate the influence of protein intake upon the outcome effects of hypocaloric feeding. DESIGN A meta-analysis of randomized controlled trials (RCTs) and trial sequential analysis (TSA) were carried out. SETTING Intensive Care Unit (ICU). PATIENTS Or participants Critically ill adults. INTERVENTIONS Hypocaloric enteral feeding versus standard enteral feeding. MAIN VARIABLES OF INTEREST The primary outcomes were all-cause short-term mortality and the incidence of nosocomial infection. RESULTS Eleven RCTs met the inclusion criteria; of these trials, two were judged as having low risk of bias. Compared with standard enteral feeding, hypocaloric enteral feeding had no benefits in terms of reducing short-term mortality, the incidence of nosocomial infection, or long-term mortality, though it had a positive impact upon the incidence of gastrointestinal intolerance. The TSA further confirmed these results. In turn, hypocaloric enteral feeding had no effects upon the incidence of bloodstream infection, pneumonia, hypoglycemia or the duration of mechanical ventilation, ICU stay, or in-hospital stay. The above results remained unchanged in the sub-analysis of trials with a low risk of bias, trials administering a similar dose of protein, or trials administering different doses of protein. CONCLUSIONS Compared with standard enteral feeding, hypocaloric enteral feeding was not associated with better clinical outcomes in critically ill adults, except for a lower risk of gastrointestinal intolerance. The difference in protein intake between groups might have no influence on the outcome effects of hypocaloric enteral feeding. High quality randomized controlled trials are needed to confirm this, however.
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Affiliation(s)
- X Zhou
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - H Fang
- Department of Emergency, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang 315000, China
| | - C Hu
- Department of Intensive Care Medicine, Zhejiang Hospital, Hangzhou, Zhejiang 310000, China.
| | - J Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - H Wang
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - J Pan
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Y Sha
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China
| | - Z Xu
- Department of Intensive Care Medicine, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang 315000, China.
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Marik PE. Nutritional Support Among Medical Inpatients-Feed the Cold (and Malnourished) and Starve the Febrile. JAMA Netw Open 2019; 2:e1915707. [PMID: 31747027 DOI: 10.1001/jamanetworkopen.2019.15707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk
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31
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
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).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Chourdakis M, Heyland DK. Reply-letter to the editor-harm associated with higher energy intake in patients with Low-mNUTRIC score should not be ignored. Clin Nutr 2019; 38:2474-2475. [PMID: 31196676 DOI: 10.1016/j.clnu.2019.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Michael Chourdakis
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
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Hung KY, Chen YM, Wang CC, Wang YH, Lin CY, Chang YT, Huang KT, Lin MC, Fang WF. Insufficient Nutrition and Mortality Risk in Septic Patients Admitted to ICU with a Focus on Immune Dysfunction. Nutrients 2019; 11:nu11020367. [PMID: 30744171 PMCID: PMC6412372 DOI: 10.3390/nu11020367] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 12/29/2022] Open
Abstract
Immune dysfunction is seen both in sepsis patients and in those with malnutrition. This study aimed to determine whether insufficient nutrition and immune dysfunction have a synergistic effect on mortality in critically ill septic patients. We conducted a prospective observational study from adult sepsis patients admitted to intensive care units (ICUs) between August 2013 and June 2016. Baseline characteristics including age, gender, body mass index, NUTRIC, Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were recorded. Immune dysfunction, defined by human leukocyte antigen DR (HLA-DR) expression, was tested at days 1, 3, and 7 of ICU admission. The study included 151 patients with sepsis who were admitted to the ICU. The 28-day survivors had higher day 7 caloric intakes (89% vs. 73%, p = 0.042) and higher day 1-HLA-DR expression (88.4 vs. 79.1, p = 0.045). The cut-off points of day 7 caloric intake and day 1-HLA-DR determined by operating characteristic curves were 65.1% and 87.2%, respectively. Immune dysfunction was defined as patients with day 1-HLA-DR < 87.2%. Insufficient nutrition had no influence on survival outcomes in patients with immune dysfunction. However, patients with insufficient nutrition had poor prognosis when they were immune competent. Insufficient nutrition and immune dysfunction did not have a synergistic effect on mortality in critically ill septic patients.
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Affiliation(s)
- Kai-Yin Hung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
- Department of nutritional Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan.
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan.
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 813, Taiwan.
| | - Yi-Hsi Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
| | - Chiung-Yu Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
| | - Ya-Ting Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
| | - Kuo-Tung Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 813, Taiwan.
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung 833, Taiwan.
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 813, Taiwan.
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Arabi Y, Jawdat D, Bouchama A, Tamim H, Tamimi W, Al-Balwi M, Al-Dorzi HM, Sadat M, Afesh L, Abdullah ML, Mashaqbeh W, Sakhija M, Hussein MA, ElObeid A, Al-Dawood A. Permissive underfeeding, cytokine profiles and outcomes in critically ill patients. PLoS One 2019; 14:e0209669. [PMID: 30615631 PMCID: PMC6322779 DOI: 10.1371/journal.pone.0209669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/10/2018] [Indexed: 01/26/2023] Open
Abstract
Background During critical illness in humans, the effects of caloric restriction on the inflammatory response are not well understood. The aim of this study is to examine the associations of caloric restriction, inflammatory response profiles and outcomes in critically ill patients. Methods This is a sub-study of the PermiT trial (Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults Trial- ISRCTN68144998). Serum samples were collected on study days 1, 3, 5, 7 and 14 and analyzed for a panel of 29 cytokines. We used principal component analysis to convert possibly correlated variables (cytokine levels) into a limited number of linearly uncorrelated variables (principal components). We constructed repeated measures mixed linear models to assess whether permissive underfeeding compared to standard feeding was associated with difference cytokine levels over time. Results A total of 72 critically ill patients were enrolled in this study (permissive underfeeding n = 36 and standard feeding n = 36). Principal component analysis identified 6 components that were responsible for 78% of the total variance. When adjusted to principal components, permissive underfeeding was not associated with 90-day mortality (adjusted odds ratio 1.75, 95% confidence interval 0.44, 6.95, p = 0.43) or with incident renal replacement therapy. The cytokines did not differ with time between permissive underfeeding and standard feeding groups. Conclusions The association of permissive underfeeding compared to standard feeding with mortality was not influenced by the inflammatory profile. Permissive underfeeding compared to standard feeding was not associated with differences in the serum levels of cytokines in critically ill patients.
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Affiliation(s)
- Yaseen Arabi
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- * E-mail: ,
| | - Dunia Jawdat
- Cord Blood Bank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abderrezak Bouchama
- Department of Experimental Medicine, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Waleed Tamimi
- Department of Clinical Laboratory, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed Al-Balwi
- Department of Clinical Laboratory, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hasan M. Al-Dorzi
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Lara Afesh
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mashan L. Abdullah
- Department of Experimental Medicine, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Walid Mashaqbeh
- Cord Blood Bank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Maram Sakhija
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohamed A. Hussein
- Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Adila ElObeid
- Department of Biobank, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdulaziz Al-Dawood
- Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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35
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Differential Gene Expression in Peripheral White Blood Cells with Permissive Underfeeding and Standard Feeding in Critically Ill Patients: A Descriptive Sub-study of the PermiT Randomized Controlled Trial. Sci Rep 2018; 8:17984. [PMID: 30573851 PMCID: PMC6301949 DOI: 10.1038/s41598-018-36007-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 11/14/2018] [Indexed: 01/08/2023] Open
Abstract
The effect of short-term caloric restriction on gene expression in critically ill patients has not been studied. In this sub-study of the PermiT trial (Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults Trial- ISRCTN68144998), we examined gene expression patterns in peripheral white blood cells (buffy coat) associated with moderate caloric restriction (permissive underfeeding) in critically ill patients compared to standard feeding. Blood samples collected on study day 1 and 14 were subjected to total RNA extraction and gene expression using microarray analysis. We enrolled 50 patients, 25 in each group. Among 1751 tested genes, 332 genes in 12 pathways were found to be significantly upregulated or downregulated between study day 1 and 14 (global p value for the pathway ≤ 0.05). Using the heatmap, the differential expression of genes from day 1 to 14 in the permissive underfeeding group was compared to the standard feeding group. We further compared gene expression signal intensity in permissive underfeeding compared standard feeding by constructing univariate and multivariate linear regression models on individual patient data. We found differential expression of several genes with permissive underfeeding, most notably those related to metabolism, autophagy and other cellular functions, indicating that moderate differences in caloric intake trigger different cellular pathways.
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36
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Chourdakis M, Grammatikopoulou MG, Day AG, Bouras E, Heyland DK. Are all low-NUTRIC-score patients the same? Analysis of a multi-center observational study to determine the relationship between nutrition intake and outcome. Clin Nutr 2018; 38:2783-2789. [PMID: 30579667 DOI: 10.1016/j.clnu.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/10/2018] [Accepted: 12/03/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The NUTrition Risk in the Critically Ill (NUTRIC) scoring system is a tool useful, discriminating critically-ill patients benefiting from optimal nutrition intake (>80% of prescription). Recent recommendations advocate for withholding artificial nutrition among low-NUTRIC patients, however, we hypothesized that some low-NUTRIC patients would show an association between nutrition intake and outcome. METHODS Patients were selected from the 2013-2014 International Nutrition Surveys when ICU length of stay (LICU) ≥72 h, baseline mNUTRIC score ≤4 and had at least three evaluable nutrition days (N = 2781). Proportion of prescription received during evaluable days was associated to 60-day hospital mortality by a logistic regression modelling. A priori, we expected that the association between proportion of prescription received and mortality might differ according to: LICU, BMI and prior unintentional weight loss or reduced oral intake. RESULTS A total of 2781 patients fulfilled the inclusion criteria and participated in the study. Ten percent of the sample had a BMI <20 kg/m2 and 20% experienced either unintentional weight loss during the last 3 months, or reduced food intake over the last week. Sixty-day hospital mortality was 15% and median LICU reached 11.3 [6.3-21.7] days. Mean total prescription received by any means of nutritional support during the first 12 evaluable days was 57.4 ± 28.1% for energy and 53.7 ± 29.2% for protein. In the pooled, subgroup and sensitivity analyses, no significant associations were identified. CONCLUSION Low-NUTRIC (≤4) patients demonstrate a prolonged LICU, while experiencing significant mortality and a high prevalence of malnutrition risk factors. Although improvements in mortality were not achieved with increased nutritional intake, this should not be construed as a rationale for withholding artificial nutrition among this patient group.
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Affiliation(s)
- Michael Chourdakis
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Maria G Grammatikopoulou
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Andrew G Day
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Emmanouil Bouras
- Department of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada; Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
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37
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Tamion F, Bohé J. Comment je prends en charge la nutrition d’un patient en état de choc. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La réponse métabolique à l’agression correspond à un ensemble de réactions à la base de l’adaptation de l’organisme aux nouvelles conditions. Ces modifications concernent des aspects métaboliques spécifiques comme le maintien de la masse protéique et/ou l’état des réserves énergétiques. L’une des principales difficultés de l’optimisation du support métabolique consiste à distinguer les changements métaboliques bénéfiques de ceux qui sont délétères pour l’organisme. Dans ce contexte, les objectifs thérapeutiques peuvent se limiter à une approche nutritionnelle s’attachant à limiter le déficit énergétique et les pertes protéiques et musculaires. Ils peuvent être plus ambitieux en essayant d’adapter les apports aux différents besoins d’un point de vue quantitatif comme qualitatif. La limitation du déficit énergétique semble être un objectif raisonnable à atteindre selon les données de la littérature. Enfin, essayer d’interférer avec la réponse métabolique à l’agression (immunomodulation, manipulations pharmacologiques des voies métaboliques, etc.) représente le degré d’intervention métabolique le plus élaboré et, si quelques données ont pu être encourageantes, il n’est pas possible d’affirmer que cet objectif soit complètement réaliste, voire même bénéfique. Les apports nutritionnels doivent être intégrés à la stratégie thérapeutique globale de prise en charge. La réponse optimale du support nutritionnel a pour but « de donner les moyens métaboliques » de la guérison.
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Olthof LE, Koekkoek WK, van Setten C, Kars JC, van Blokland D, van Zanten AR. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study. Clin Nutr 2018; 37:1609-1617. [DOI: 10.1016/j.clnu.2017.08.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/08/2017] [Accepted: 08/03/2017] [Indexed: 12/15/2022]
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ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2018; 38:48-79. [PMID: 30348463 DOI: 10.1016/j.clnu.2018.08.037] [Citation(s) in RCA: 1321] [Impact Index Per Article: 220.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.
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Tadlock MD, Hannon M, Davis K, Lancman M, Pamplin J, Shackelford S, Martin M, Stockinger Z. Nutritional Support Using Enteral and Parenteral Methods. Mil Med 2018; 183:153-160. [PMID: 30189073 DOI: 10.1093/milmed/usy074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Indexed: 11/14/2022] Open
Abstract
The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.
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Affiliation(s)
- Matthew D Tadlock
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Hannon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Konrad Davis
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Micah Lancman
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jeremy Pamplin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Stacy Shackelford
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Matthew Martin
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Abstract
Intensive care unit (ICU)-acquired weakness frequently complicates critical illness, which prolongs intensive care dependency and causes long-term burden. Observational studies have suggested that prolonged underfeeding could aggravate ICU-acquired weakness and impair outcome. However, recent large randomized controlled trials have failed to show a benefit of early enhanced nutrition to critically ill patients. Moreover, early parenteral nutrition was even shown to increase ICU-acquired weakness and prolong organ failure and intensive care dependency, which may be explained by feeding-induced suppression of autophagy. Currently, the ideal timing of artificial nutrition for critically ill patients as well as the optimal dose and composition remain unclear.
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Affiliation(s)
- Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Lewis SR, Schofield‐Robinson OJ, Alderson P, Smith AF. Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit. Cochrane Database Syst Rev 2018; 6:CD012276. [PMID: 29883514 PMCID: PMC6353207 DOI: 10.1002/14651858.cd012276.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition. OBJECTIVES To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting. AUTHORS' CONCLUSIONS We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
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Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
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Abstract
PURPOSE OF REVIEW Feeding guidelines have recommended early, full nutritional support in critically ill patients to prevent hypercatabolism and muscle weakness. Early enteral nutrition was suggested to be superior to early parenteral nutrition. When enteral nutrition fails to meet nutritional target, it was recommended to administer supplemental parenteral nutrition, albeit with a varying starting point. Sufficient amounts of amino acids were recommended, with addition of glutamine in subgroups. Recently, several large randomized controlled trials (RCTs) have yielded important new insights. This review summarizes recent evidence with regard to the indication, timing, and dosing of parenteral nutrition in critically ill patients. RECENT FINDINGS One large RCT revealed no difference between early enteral nutrition and early parenteral nutrition. Two large multicenter RCTs showed harm by early supplementation of insufficient enteral nutrition with parenteral nutrition, which could be explained by feeding-induced suppression of autophagy. Several RCTs found either no benefit or harm with a higher amino acid or caloric intake, as well as harm by administration of glutamine. SUMMARY Although unanswered questions remain, current evidence supports accepting low macronutrient intake during the acute phase of critical illness and does not support use of early parenteral nutrition. The timing when parenteral nutrition can be initiated safely and effectively is unclear.
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Hoffer LJ. High-Protein Hypocaloric Nutrition for Non-Obese Critically Ill Patients. Nutr Clin Pract 2018; 33:325-332. [PMID: 29701916 DOI: 10.1002/ncp.10091] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
High-protein hypocaloric nutrition, tailored to each patient's muscle mass, protein-catabolic severity, and exogenous energy tolerance, is the most plausible nutrition therapy in protein-catabolic critical illness. Sufficient protein provision could mitigate the rapid muscle atrophy characteristic of this disease while providing urgently needed amino acids to the central protein compartment and sites of tissue injury. The protein dose may range from 1.5 to 2.5 g protein (1.8-3.0 g free amino acids)/kg dry body weight per day. Nutrition should be low in energy (≈70% of energy expenditure or ≈15 kcal/kg dry body weight per day) because efforts to match energy provision to energy expenditure are physiologically irrational, risk toxic energy overfeeding, and have repeatedly failed in large clinical trials to demonstrate clinical benefit. The American Society for Parenteral and Enteral Nutrition currently suggests high-protein hypocaloric nutrition for obese critically ill patients. Short-term high-protein hypocaloric nutrition is physiologically and clinically sensible for most protein-catabolic critically ill patients, whether obese or not.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Hartl WH, Bender A, Scheipl F, Kuppinger D, Day AG, Küchenhoff H. Calorie intake and short-term survival of critically ill patients. Clin Nutr 2018; 38:660-667. [PMID: 29709380 DOI: 10.1016/j.clnu.2018.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/13/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The association between calorie supply and outcome of critically ill patients is unclear. Results from observational studies contradict findings of randomized studies, and have been questioned because of unrecognized confounding by indication. The present study wanted to re-examine the associations between the daily amount of calorie intake and short-term survival of critically ill patients using several novel statistical approaches. METHODS 9661 critically ill patients from 451 ICUs were extracted from an international database. We examined associations between survival time and three pragmatic nutritional categories (I: <30% of target, II: 30-70%, III: >70%) reflecting different amounts of total daily calorie intake. We compared hazard ratios for the 30-day risk of dying estimated for different hypothetical nutrition support plans (different categories of daily calorie intake during the first 11 days after ICU admission). To minimize indication bias, we used a lag time between nutrition and outcome, we particularly considered daily amounts of calorie intake, and we adjusted results to the route of calorie supply (enteral, parenteral, oral). RESULTS 1974 patients (20.4%) died in hospital before day 30. Median of daily artificial calorie intake was 1.0 kcal/kg [IQR 0.0-4.1] in category I, 12.3 kcal/kg [9.4-15.4] in category II, and 23.5 kcal/kg [19.5-27.8] in category III. When compared to a plan providing daily minimal amounts of calories (category I), the adjusted minimal hazard ratios for a delayed (from day 5-11) or an early (from day 1-11) mildly hypocaloric nutrition (category II) were 0.71 (95% confidence interval [CI], 0.54 to 0.94) and 0.56 (95% CI, 0.38 to 0.82), respectively. No substantial hazard change could be detected, when a delayed or an early, near target calorie intake (category III) was compared to an early, mildly hypocaloric nutrition. CONCLUSIONS Compared to a severely hypocaloric nutrition, a mildly hypocaloric nutrition is associated with a decreased risk of death. In unselected critically ill patients, this risk cannot be reduced further by providing amounts of calories close to the calculated target. STUDY REGISTRATION ID number ISRCTN17829198, website http://www.isrctn.org.
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Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, Transplantation, and Vascular Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Andreas Bender
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
| | - Fabian Scheipl
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
| | - David Kuppinger
- Department of General, Visceral, Transplantation, and Vascular Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilians-Universität, Munich, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Helmut Küchenhoff
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
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Wesselink E, Koekkoek KWAC, Looijen M, van Blokland DA, Witkamp RF, van Zanten ARH. Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study. Clin Nutr ESPEN 2018; 25:78-86. [PMID: 29779822 DOI: 10.1016/j.clnesp.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms. METHODS This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression. RESULTS In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245). CONCLUSIONS Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.
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Affiliation(s)
- Evertine Wesselink
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Kristine W A C Koekkoek
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Martijn Looijen
- Department of Information Technology and Datawarehouse, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
| | - Dick A van Blokland
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
| | - Renger F Witkamp
- Division of Human Nutrition, Wageningen University, Stippeneng 4, 6708 WE, Wageningen, The Netherlands.
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716, Ede, The Netherlands.
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Phan KA, Dux CM, Osland EJ, Reade MC. Effect of hypocaloric normoprotein or trophic feeding versus target full enteral feeding on patient outcomes in critically ill adults: a systematic review. Anaesth Intensive Care 2018; 45:663-675. [PMID: 29137575 DOI: 10.1177/0310057x1704500604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Uncertainty surrounds the optimal approach to feeding the critically ill, with increasing interest in the concept of intentional underfeeding to reduce metabolic stress while maintaining gut integrity. Conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, this systematic review evaluates clinical outcomes reported in studies comparing hypocaloric normonitrogenous or trophic feeding (collectively 'intentional underfeeding') targeted full energy feeding administered via enteral nutrition to adult critically ill patients. Electronic databases including PubMed, CINAHL, EMBASE and CENTRAL were searched up to September 2017 for trials evaluating intentional underfeeding versus targeted energy feeding interventions on clinical outcomes (mortality, length of stay, duration of ventilation, infective complications, feeding intolerance and glycaemic control) among critically ill adult patients. Bias of included studies was assessed using the Cochrane risk of bias tool. Of the 595 articles identified, seven studies (six randomised controlled trials, one non-randomised trial) met the inclusion criteria, representing 2,684 patients (hypocaloric normonitrogenous n=668; trophic n=681; full energy feeding n=1335). Across the studies, there was considerable heterogeneity in study methodology, population, feeding strategy and outcomes and their timepoints. We observed no evidence that intentional underfeeding, when compared to targeting full energy feeding, reduced mortality or duration of ventilation or length of stay. However, limited trial evidence is available on the impact of intentional underfeeding on post-discharge functional and quality of life outcomes.
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Affiliation(s)
| | | | | | - M C Reade
- Intensivist, Intensive Care Medicine, University of Queensland and Burns, Trauma and Critical Care Research Centre, Brisbane, Queensland, Joint Health Command, Australian Defence Force, Canberra, Australian Capital Territory
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Silva CFA, de Vasconcelos SG, da Silva TA, Silva FM. Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials. Nutr Clin Pract 2018; 33:388-396. [PMID: 29377333 DOI: 10.1002/ncp.10001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.
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Affiliation(s)
- Camila F A Silva
- Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Thales A da Silva
- Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Flávia M Silva
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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