Metabolic, Electrolytes, and Nutritional Concerns in Critical Illness

Nutritional adequacy in critically ill patients: Result of PNSI study

BACKGROUND & AIMS

Critically ill patients are provided with the intensive care medicine to prevent further complications, including malnutrition, disease progression, and even death. This study was intended to assess nutritional support and its' efficacy in the Intensive Care Units (ICUs) of Iran.

METHODS

This cross-sectional study assessed 50 ICU's patients out of 25 hospitals in the 10 major regions of Iran's health system and was performed using the multistage cluster sampling design. The data were collected from patient's medical records, ICU nursing sheets, patients or their relatives from 2017 to 2018. Nutritional status was investigated by modified NUTRIC score and food frequency checklist.

RESULTS

This study included 1321 ICU patients with the mean age of 54.8 ± 19.97 years, mean mNUTRIC score of 3.4 ± 2.14, and malnutrition rate of 32.6%. The mean time of first feeding was the second day and most of patients (66%) received nutrition support, mainly through enteral (57.2%) or oral (37%) route during ICU stay. The patients received 59.2 ± 37.78 percent of required calorie and 55.5 ± 30.04 percent of required protein. Adequate intake of energy and protein was provided for 16.2% and 10.7% of the patients, respectively. The result of regression analysis showed that the odds ratio of mNUTRIC score was 0.85 (95% confidence interval [CI] = 0.74-0.98) and APACHE II was 0.92 (95%CI = 0.89-0.95) for the prediction of energy deficiency. Nutrition intake was significantly different from patient's nutritional requirements both in terms of energy (p < 0.001) and protein (p < 0.001). Also, mean mNUTRIC score varied notably (p = 0.011) with changing in energy intake, defined as underfeeding, adequate feeding, and overfeeding.

CONCLUSION

The present findings shown that, provided nutritional care for ICU patients is not adequate for their requirements and nutritional status.

Fluids for Prevention and Management of Acute Kidney Injury

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.

Safety of Compounded Calcium Chloride Admixtures for Peripheral Intravenous Administration in the Setting of a Calcium Gluconate Shortage

Calcium gluconate is preferred over calcium chloride for intravenous (IV) repletion of calcium deficiencies in the inpatient setting. In the setting of a national shortage of IV calcium gluconate, our institution implemented a compounded calcium chloride admixture for IV administration. The objective of this analysis is to evaluate the peripheral infusion site safety of compounded IV calcium chloride admixtures in adult inpatients. A total of 222 patients, encompassing 224 inpatient admissions, from April to June 2011 were retrospectively reviewed. Sterile preparations of calcium chloride in 5% dextrose (600 mg/250 mL and 300 mg/100 mL) were used during the study time period. Adverse infusion site reactions were assessed using an institutional infiltration and phlebitis grading system. A total of 333 doses were administered peripherally. In all, 4 (1.8%) patients experienced a moderate to severe infusion site reaction, with 3 due to phlebitis and 1 due to infiltration. Naranjo Nomogram for Adverse Drug Reaction Assessment classified all 4 reactions to have a possible link to calcium chloride administration. Peripheral administration of compounded calcium chloride admixtures in 5% dextrose is associated with a low incidence of IV infusion site reactions and can be considered as an alternative in the event of a calcium gluconate shortage.

Ionized hypocalcemia is an early event and is associated with organ dysfunction in children admitted to the intensive care unit

PURPOSE

The purpose was to determine the frequency and risk factors of ionized hypocalcemia and to evaluate this disturbance as a predictor of mortality in a pediatric intensive care unit (ICU).

MATERIALS AND METHODS

In a prospective cohort study, 337 children admitted consecutively to an ICU were monitored regarding serum ionized calcium concentrations during the first 10 days of admission. The following variables were analyzed as independent of hypocalcemia: age; malnutrition; sepsis; Pediatric Index of Mortality 2; first 3 days organ dysfunction score (Pediatric Logistic Organ Dysfunction); and use of steroids, furosemide, and anticonvulsants. Hypocalcemia was defined as a serum ionized calcium concentration less than 1.15 mmol/L.

RESULTS

The rate of hypocalcemia was 77.15%. In a multivariate model, higher Pediatric Logistic Organ Dysfunction scores during the first 3 days of ICU stay were independently associated with hypocalcemia (odds ratio, 2.24; 95% confidence interval, 1.23-4.07; P=.008). Medications associated with hypocalcemia were furosemide (dose≥2 mg/[kg d]) and methylprednisolone (dose≥2 mg/[kg d]). No significant association was found between hypocalcemia and 10-day mortality.

CONCLUSIONS

Ionized hypocalcemia is common during the ICU stay, particularly in the first 3 days of admission. This disturbance was not found to be a predictor of mortality, but it is independently associated with more severe organ dysfunction.

Inadequate energy delivery during early critical illness correlates with increased risk of mortality in patients who survive at least seven days: a retrospective study

BACKGROUND & AIMS

We examined associations between the first-week energy and protein intake and clinical outcomes in medical ICU (MICU) patients who survived at least seven days.

METHODS

We retrospectively studied 295 patients admitted to a 28-bed MICU between 2005 and 2007. High and low energy delivery (ED) and protein delivery (PD) were defined as having a mean daily intake relative to recommendation at ≥ 60% and <60%, respectively, during the 1st to 7th day of ICU stay.

RESULTS

The high and low ED or PD groups did not differ with regard to length of ICU stay, length of hospital stay, or ventilator free time. Patients with low ED or low PD intake were at greater risk of mortality than their high intake counterparts (OR = 3.7 and 3.6; both p < 0.001). After adjusting for confounders, we found patients receiving low ED to be at 2.43 times the risk of ICU mortality than high ED (p = 0.020). Low PD was unrelated to ICU mortality.

CONCLUSIONS

Patients receiving less than 60% of recommended energy intake during the first week of critical illness are at greater risk of mortality. There is a need for future randomized trials to investigate optimal energy delivery during critical illness.

Understanding, recognizing, and managing chronic critical illness syndrome

PURPOSE

No evidence-based guidelines exist for the care of patients with chronic critical illness syndrome (CCIS), a growing population of patients being cared for by nurse practitioners (NPs). The purpose of this article is to provide NPs with a beginning physiological framework, allostasis, to guide their understanding and management of patients with CCIS.

DATA SOURCES

Scientific publications, related clinical guidelines.

CONCLUSIONS

Patients with CCIS are a distinct group of critically ill patients whose care needs are different from those of patients who are acutely critically ill. These patients demonstrate widespread tissue and organ damage. The widespread tissue and organ damage results in a syndrome of interrelated elements, which include neuroendocrine problems, severe malnutrition, wounds, infections, bone loss, polyneuropathy and myopathy, delirium and depression, and suffering.

IMPLICATIONS FOR PRACTICE

In caring for patients with CCIS, NPs need to focus on treating the elements of the syndrome as a cohort of interrelated elements and on re-establishing normalcy for the patient.

The protein equivalent of nitrogen appearance in critically ill acute renal failure patients undergoing continuous renal replacement therapy

OBJECTIVE

To assess the nutritional status of critically ill patients with acute renal failure on continuous renal replacement therapy (CRRT) and their protein needs by estimating the protein equivalent of nitrogen appearance (PNA).

DESIGN

Prospective, observational study.

SETTING

A 74-bed intensive care unit in a single tertiary care hospital.

PATIENTS

Twenty-five consecutive critically ill patients with acute renal failure on CRRT.

METHODS

The patients were studied over a period of 24 hours, at initiation on CRRT. The nutritional status was assessed by anthropometry and bioimpedance analysis. The PNA was estimated using the Bergstrom equation and PNA was normalized to body weight.

RESULTS

The mean age was 58.2 +/- 17 years and 20 (80%) were male. The mean weight was 67 +/- 12 kg, body mass index was 25 +/- 3.5 kg/m(2), and triceps and subscapular skin fold thickness were 13 +/- 4.6 mm and 15 +/- 2.5 mm, respectively. Bioimpedance studies showed that the total body water was increased at 61.7 +/- 5.5% and body fat was 31.8 +/- 5.4%. The PNA was 103 +/- 35 g/day and normalized PNA was 1.57 +/- 0.4 g/kg/day. The mean protein intake was 0.56 +/- 0.38 g/kg/day, resulting in mean net negative protein balance of 1.0 +/- 0.6 g/kg/day.

CONCLUSIONS

Malnutrition was uncommon in patients with acute renal failure at the time of initiation on CRRT, but their total body water was increased. They exhibited hypercatabolism and the mean normalized PNA was 1.57 g/kg/day. A large negative nitrogen balance was observed in them, since their protein intake was suboptimal.

Severe hypophosphataemia mimicking Guillain-Barré syndrome

A 42 year-old woman presented with neurological symptoms suggestive of Guillain-Barré syndrome and required ventilatory support. She was found to have severe hypophosphataemia that was corrected promptly after which her trachea was extubated. She then revealed that she had undergone a prolonged religious fast and had just started eating again when her symptoms started. Over the next 2 weeks she made a complete recovery.

Transpyloric enteral nutrition in the critically ill child with renal failure

OBJECTIVE

To study the efficacy and tolerance of transpyloric enteral nutrition (TEN) in the critically ill child with acute renal failure (ARF).

DESIGN

Prospective observational study.

SETTING

Paediatric intensive care unit.

PATIENTS

Critically ill children with ARF who received TEN were included in the study. They were compared with the remaining 473 critically ill children receiving TEN in this period. Tolerance of nutrition and gastrointestinal complications were assessed.

INTERVENTION

Transpyloric enteral nutrition.

MEASUREMENTS AND RESULTS

Fifty-three critically ill children with ARF aged between 3 days and 17 years received TEN. Children with ARF more frequently received parenteral nutrition before TEN (56.6%) than the other patients (17.5%). The incidence of shock, hepatic alterations and mortality was significantly higher in patients with ARF than in the remaining children. In children with ARF the mean duration of the TEN was 16.5-27.3 days and the maximum caloric intake was 77-26.7 kcal/kg/day. Thirteen patients (24.5%) presented gastrointestinal complications, 9 (17%) abdominal distension and/or excessive gastric residue, 5 (9.4%) diarrhoea, 1 necrotising enterocolitis and 1 duodenal perforation. The frequency of gastrointestinal complications was significantly higher in children with ARF. TEN was definitive suspended in five patients due to gastrointestinal complications. Four of these patients were treated with continuous renal replacement therapy. Thirty percent of patients died during TEN. In only one patient was the death related to complications of the nutrition.

CONCLUSIONS

Critically ill children with ARF tolerate TEN, although the incidence of gastrointestinal complications is higher than in other critically ill children.

Alterations in electrolyte equilibrium in patients with acute leukemia

BACKGROUND AND AIM

A wide array of disturbances in electrolyte equilibrium is commonly seen in patients with acute leukemia (AL). These abnormalities present a potential hazard in these patients, as that of enhancing the cardiotoxic effects of certain chemotherapeutic regimens. The literature dealing with AL-related electrolyte abnormalities and their interactions in leukemic patients was reviewed.

DATA SYNTHESIS

Sources included MEDLINE and EMBASE. The search strategy was based on the combination of 'acute leukemia', 'electrolyte abnormalities', 'acid-base disorders', 'potassium', 'sodium', 'magnesium', 'calcium', and 'phosphorus'. References of retrieved articles were also screened. A decrease in serum potassium, mainly owing to lysozyme-induced tubular damage, appears to be one of the most frequent and potentially hazardous abnormalities. Other clinically significant metabolic perturbations include hyponatremia and hypercalcemia.

CONCLUSION

A broad spectrum of electrolyte abnormalities is encountered in the clinical setting of AL, which are related to the disease process per se and/or to the therapeutic interventions. Clinicians should be vigilant for early detection and appropriate management of these disorders before the initiation of chemotherapy regimens as well as during treatment.