Nutrition given to critically ill patients during high level/complex care (on Italian ICUs)

Tight glycemic control in critical care--the leading role of insulin sensitivity and patient variability: a review and model-based analysis

Tight glycemic control (TGC) has emerged as a major research focus in critical care due to its potential to simultaneously reduce both mortality and costs. However, repeating initial successful TGC trials that reduced mortality and other outcomes has proven difficult with more failures than successes. Hence, there has been growing debate over the necessity of TGC, its goals, the risk of severe hypoglycemia, and target cohorts. This paper provides a review of TGC via new analyses of data from several clinical trials, including SPRINT, Glucontrol and a recent NICU study. It thus provides both a review of the problem and major background factors driving it, as well as a novel model-based analysis designed to examine these dynamics from a new perspective. Using these clinical results and analysis, the goal is to develop new insights that shed greater light on the leading factors that make TGC difficult and inconsistent, as well as the requirements they thus impose on the design and implementation of TGC protocols. A model-based analysis of insulin sensitivity using data from three different critical care units, comprising over 75,000h of clinical data, is used to analyse variability in metabolic dynamics using a clinically validated model-based insulin sensitivity metric (S(I)). Variation in S(I) provides a new interpretation and explanation for the variable results seen (across cohorts and studies) in applying TGC. In particular, significant intra- and inter-patient variability in insulin resistance (1/S(I)) is seen be a major confounder that makes TGC difficult over diverse cohorts, yielding variable results over many published studies and protocols. Further factors that exacerbate this variability in glycemic outcome are found to include measurement frequency and whether a protocol is blind to carbohydrate administration.

Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized controlled trial

OBJECTIVE

To compare the effectiveness of active to passive dissemination of the Canadian clinical practice guidelines (CPGs) for nutrition support for the mechanically ventilated critically ill adult patient.

DESIGN

A cluster-randomized trial with a cross-sectional outcome assessment at baseline and 12 months later.

SETTING

Intensive care units in Canada.

PATIENTS

Consecutive samples of mechanically ventilated patients at each time period.

INTERVENTIONS

In the active group, we provided multifaceted educational interventions including Web-based tools to dietitians. In the passive group, we mailed the CPGs to dietitians.

MEASUREMENTS AND MAIN RESULTS

The primary end point of this study was nutritional adequacy of enteral nutrition; secondary end points measured were compliance with the CPGs, glycemic control, duration of stay in intensive care unit and hospital, and 28-day mortality. Fifty-eight sites were randomized. At baseline and follow-up, 623 and 612 patients were evaluated. Both groups were well matched in site and patient characteristics. Changes in enteral nutrition adequacy between the active and passive arms were similar (8.0% vs. 6.2 %, p = .54). Median time spent in the target glucose range increased 10.1% in the active compared with 1.8% in the passive group (p = .001). In the subgroup of medical patients, enteral nutrition adequacy improved more in the active arm compared with the passive group (by 8.1%, p = .04), whereas no such differences were observed in surgical patients. When groups were combined, during the year of dissemination activities, there was an increase in enteral nutrition adequacy (from 43% to 50%, p < .001), an increase in the use of feeding protocols (from 64% to 76%, p = .03), and a decrease in patients on parenteral nutrition (from 26% to 21%, p = .04). There were no differences in clinical outcomes between groups or across time periods.

CONCLUSIONS

Although active dissemination of the CPGs did improve glycemic control, it did not change other nutrition practices or patient outcomes except in a subgroup of medical patients. Overall, dissemination of the CPGs improved other important nutrition support practices but was not associated with improvements in clinical outcomes.

Early enteral immunonutrition vs. parenteral nutrition in critically ill patients without severe sepsis: a randomized clinical trial

OBJECTIVES

We compared early parenteral nutrition (PN) and early enteral immunonutrition (iEN) in critically ill patients, distinguishing those with and without severe sepsis or septic shock (SS) on admission to intensive care units (ICUs).

DESIGN AND SETTING

Multicenter, randomized, unblinded clinical trial in 33 Italian general ICUs.

PATIENTS AND PARTICIPANTS

The study included 326 patients, 287 of whom did not have SS on ICU admission. Eligibility criteria excluded the two tails in the spectrum of critical conditions, i.e., patients either too well or too ill. Of the patients recruited 160 were randomized to iEN (142 without SS) and 166 to PN (145 without SS).

INTERVENTIONS

Patients were randomized to two arms: early iEN or early PN.

MEASUREMENTS AND RESULTS

Primary endpoint was 28-day mortality for all patients and the occurrence of SS during ICU stay for patients admitted without such condition. While 28-day mortality did not differ between iEN and PN (15.6% vs. 15.1%), patients without SS who received iEN had fewer episodes of severe sepsis or septic shock (4.9% vs. 13.1%). ICU length of stay was 4 days shorter in patients given iEN.

CONCLUSIONS

Compared to parenteral nutrition iEN appears to be beneficial in critical patients without severe sepsis or septic shock. Parenteral nutrition in these patients should be abandoned, at least when enteral nutrition can be administered, even at an initial low caloric content.

Outcomes in a pediatric intensive care unit before and after the implementation of a nutrition support team

BACKGROUND

We evaluated the effect of parenteral nutrition (PN) and enteral nutrition (EN) on in-pediatric intensive care unit (PICU) mortality before and after a continuous education program in nutrition support that leads to implementation of a nutrition support team (NST).

METHODS

We used a historical cohort study of infants hospitalized for >72 hours at the PICU from 1992 to 2003. Five periods were selected (P1 to P5), considering the modifications incorporated into the program: P1, without intervention; P2, basic themes and original articles discussion; P3, clinical and nursing staff participation; P4, clinical visits; P5, NST. The samples were compared in terms of sex, age, admitting service (ie, medical vs surgical), prognostic index of mortality, length of stay (LOS), duration of mechanical ventilation, in-PICU mortality rate, and percentage of time receiving EN and PN for each patient. Bi- and multivariate analyses were performed. Statistical significance was set at 0.05 level.

RESULTS

Progressive increase was observed in EN use (p = .0001), median values for which were 25% in P1 and rose to 67% by P5 in medical patients; there was no significant difference in surgical patients. A reduction was observed in PN use; in P1 medians were 73% and 69% for medical and surgical patients respectively, and decreased to 0% in P5 for both groups (p = .0001). There was significant reduction in-PICU mortality rate during P4 and P5 among medical patients (p < .001). The risk of death was 83% lower in patients that received EN for >50% of LOS (odds ratio, 0.17; confidence interval, 0.066-0.412; p = .000).

CONCLUSIONS

The program motivated an increase in EN and a decrease in PN use, mainly after implementation of NST and reduced in-PICU mortality rate.